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Reflections on Cultural Authority, CAM and Chiropractic - from the ACC-RAC 2008 Conference PDF Print E-mail
Written by John Weeks   

Reflections on Cultural Authority, CAM and Chiropractic - from the ACC-RAC 2008 Conference

Summary: The theme this year for the Association of Chiropractic Colleges and Research Agenda Conference (ACC-RAC) meeting was "cultural authority."  From March 13-15, 2008, I had a chance to attend, for the first time, and present at this gathering of 350 educators, researchers, policy leaders and administrators principally based in accredited chiropractic colleges and research institutions. Despite advances on many fronts, "cultural authority" has been an elusive gold ring that chiropractic has been pursuing in recent years. The positioning around "CAM" factors in that pursuit. Here are some reflections on what I saw and heard on this theme as I moved through the conference.
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Background: The Limbo Profession

The limbo profession
Chiropractic is
the limbo profession. I shared this notion early on in a slide from my presentation March 14, 2008 at the Association of Chiropractic Colleges and the Research Agenda Conference (ACC-RAC)  Chiropractic is assigned, by the National Institutes of Health, as part of complementary and alternative medicine (CAM). Yet the very mention of that acronym in the same sentence as  "chiropractic" leads many of chiropractic's leaders to make the sign of the cross; or worse, to slash at the hand of some devil trying to drag chiropractic back down into a mire out of which it feels it is just extricating itself. CAM is seen, by these leaders, as less than chiropractic, an outsider, a reminder of poverty and non-inclusion.

Look at us
, they say: We're licensed in 50 states, covered (partly at least) by Medicare and by most employer health plans, credentialed and practicing in the Veterans' Administration facilities and making headway in other Department of Defense initiatives. We're at the table, in DC, working hard, continuously lobbying, taking on on HMO exclusions,
making headway year by year, busting back the AMA when they encroach on our rights to make a living, advancing continuously even against continuous attacks from the mainstream.

There's the rub, and the limbo for chiropractic. Despite chiropractic's advances, the field remains the licensed natural healthcare discipline that conventional medicine most loves to hate. In my own examination of hospital-based integrative clinics, only a fraction - 5 of 27 (19%) - had a chiropractor on staff. By comparison, massage therapists were in nearly 100%. Licensed acupuncturists, newer players in the field, were in 65%. Naturopathic physicians, despite only having licensure in a minority of the states in which the integrative clinics were located, were in just one fewer (4) of the clinics. And this paltry inclusion comes despite the fact that chiropractors are better integrated into the payment system and have relatively high utilization by the very consumers to whom such clinics are seeking to appeal. Why the short shrift? Typically an orthopedic surgeon who effectively has veto power in the system threatens to hold up the whole integrative undertaking if a chiropractor is involved.

In short, chiropractic has, frequently, successfully, fought its way in. However, chiropractic has much less often been invited to the table. So the question was front and center at the 2008 ACC-RAC: How can "cultural authority" be established by chiropractic?

ACC-RAC 20081.    A starting place for gaining authority: invite more outsiders to the conference

I have worked closely with many chiropractic leaders over the past decade. 
Lou Sportelli, DC, and Tino Villani, DC have supported many aspects of my work, including this newsletter. ACC's executive director David O'Bryon, past ACC chair Reed Phillips, DC, PhD, and the immediate past chair of the profession's accrediting agency, Joe Brimhall, DC, have been among my close colleagues since 2004. We've helped organize the National Education Dialogue to Advance Integrated Health Care: Creating Common Ground and the Academic Consortium for Complementary and Alternative Health Care. It was through those connections that I was invited to speak, a talk on our work with other disciplines, conventional and "CAM," to enhance interdisciplinary collaboration. In short, some of my best friends are chiropractors. Yet for all this connectivity, I must report, sheepishly, that the experience of being at ACC-RAC with these professionals, educators and scientists opened my eyes significantly to the strength and, well, authority of the profession. I met many fine, earnest professionals (and a happy number of very enjoyable souls, not necessarily a separate category), all working hard to better their profession. In a context shaped by prejudice (I received bias against chiropractic from my Bostonian Mom), connection is useful. Chiropractic would serve itself to invite more outsiders to their ACC-RAC meeting.

NYCC campus
2.    Portrait of a Community Network: The New York Chiropractic College

In this culture, one gains authority by having a golf course on campus. New York Chiropractic College has one. Well, 9 holes. More important, authority may be gained through connectivity.The upstate New York institution, located on 300 acres, also boasts a Department of Acupuncture and Oriental Medicine (AOM). Jason Wright, LAc, is president of NYCC's faculty senate. A medical doctor is on staff in the principal NYCC teaching clinic. In addition NYCC has: relationships with 5 separate Veterans' Administration hospitals; participation in a Blue Cross hospice care program; partnerships with 2 community clinics; and a further relationship with the Monroe Community Hospital.
I learned all this as a quick download from Frank Nicchi, DC, NYCC president. Nicchi is among chiropractic leaders who are not CAM-adverse. A decade ago he began attending the Harvard conferences when the "integrative medicine" discussion began. Nicchi sees value, and a potential for enhanced cultural presence, in chiropractic affirmatively linking with the other, philosophically-aligned, health-oriented natural healthcare disciplines.

JCE article, research in chiropractic education
Claire Johnson, MSEd, DC
3.    The Journal of Chiropractic Education: A Retrospective Look at Journal Articles

One tool of authority available to the chiropractors for the past 20 years is The Journal of Chiropractic Education, published by the ACC. No other "CAM" field - naturopathic medicine, AOM, or massage - has a publication dedicated to fostering and publishing the scholarly and research writings of its educators.
In Volume 22, Number 1, researcher Claire Johnson, MSEd, DC and editor Bart Green, DC, MSEd published a data-based evaluation of the articles in JCE since it was founded. The greater part of the authority in the piece was its honesty. Of the total of articles, 66% were found to be non-data in nature. A minority of schools were responsible for a vast majority of the publications. Interestingly, there appeared to be a strong correlation between the schools which had a high level of publications and those which have extended their institutions in the last decade to become multidisciplinary by adding AOM and/or naturopathic medicine programs. In short, interest in research may be correlated with interest in multidisciplinary activity. The authors recommend that in the future "more efforts and resources [should be] dedicated to data-driven studies."

Authority through integrative clinics
4.    Authority via Model Integrative Clinics: NWHSU & Woodwinds & University of Minnesota

One non-data article in the current JCE, by James Lehman, DC, MBA and Paul Suozzi, PhD, suggests that a great way for chiropractic "to build higher cultural authority" is to "found integrative centers of excellence." Lehman, a member of the faculty at the University of Bridgeport, figure that chiropractic might be able to integrate practitioners without the biases in practitioner choices and therapies seen in many conventional integrative clinics. Clinical educators with Northwestern Health Sciences University (NWHSU) - a former chiropractic school which now has programs in AOM and massage offers a model to back the theory. NHSU developed and runs an integrative clinic on the highly regarded Natural Care Center at Woodwinds Health Campus. NWHSU is also in discussions about developing and managing a clinic with the Center for Spirituality and Health at the University of Minnesota. Notably, interest in the UM partnership was stimulated by the authority NWHSU gained through its modeling of a successful integrative clinic at Woodwinds. Another indication of authority gained: NWHSU's work will be featured at the May 2008 Integrative Medicine for Health Care Organizations conference sponsored by Health Forum/American Hospital Association.

Reed Phillips, DC, PhD, founding chair of the multidisciplinary educators' consortium
5.    Authority via Mentoring: A Special Role with Emerging Natural Health Disciplines

The guild warriors among the chiropractic profession are a powerful, accomplished group. The internal line on their skill development is that they learned from the best at guild politics: "the medics" (AMA/MDs). Guild action is typically a dual visioned game: carve out more territory for yourself from those above you while not forgetting to slap down those at your heels and encroaching on your space. While the independent practice of physical therapists is particularly worrisome, the emerging licensed disciplines representing massage therapists, AOM, naturopathic physicians and even Yoga therapists can also be viewed as competitors. Chiropractors were once virtually the one and only alternative; now there are increasing numbers of others. Many chiropractors see the rise of these competitors are led by an instinct to not align. Why help them? Yet other leaders, like O'Bryon, Phillips, Brimhall, Nicchi, Chuck Sawyer, DC at NWHSU, and others see that there is a place here for chiropractic to support and mentor some of these disciplines, while also learning from them. Notably, the 2 retreats of the multidisciplinary Academic Consortium for Complementary and Alternative Health Care (ACCAHC), which I presently direct, were held in donated space at Southern California University of Health Sciences, formerly only a chiropractic college, and then Western States Chiropractic College. The third, in May 2009, will be hosted by Sawyer's NHSU. Chiropractic educators in ACCAHC have been profoundly positive and empowering players.

Image6.    Guild Resistance to CAM Alliances: Are They Above or Below Us?

Sometimes, determining who it is okay to associate with, deciding who is where in the pecking order of "cultural authority" can be challenging. I had a conversation with a group of chiropractors at the ACC-RAC who were more profession-aligned than educational institution-aligned. They were strongly opposed to any chiropractic affiliation with the "CAM" universe. One reason: To their understanding, none of the other CAM fields had gained the authority of chiropractic's status as a direct access practice. Therefore, to be identified with CAM would, by association, only invite limits. In fact, however, the assumption is not true, as I shared. First, the AOM profession in New Mexico ("Oriental Medical Doctors") and Florida ("Acupuncture Physicians") has very broad practice rights. Inside the AOM profession is a move to establish the field with more primary care authority. More significantly, the naturopathic physicians have a broader scope than chiropractors in all, or almost all, of the 14 jurisdictions in which NDs are licensed. Naturopathic practice typically also has prescribing rights - an enviable scope inclusion for any guild-oriented battler. This information, however, didn't seem to change them. Don't bother me with the facts. My mind is made up. The animus behind the decision to not collaborate, right or wrong, resonates with that in integrative medical doctors who don't have the authority to put chirorpactors in their clinics: It'll be harder for me to do what I want with you connected.

Partap S. Khalsa, DC, PhD, NCCAM program officer
7.    Authority via NIH Research? Don't Take It Personally, But, Well, No Time Soon ...

One member of the closing panel of the meeting was the lone, licensed CAM professional on staff at the NIH National Center for Complementary and Alternative Medicine (NCCAM): Partap Singh Kahlsa, DC, PhD.  Khalsa revealed that the new NCCAM director Josephine Briggs, MD, had shared with staff, more than once, that she viewed manipulative therapy as "low hanging fruit" for showing the value of CAM. Khalsa then took a useful, unusual turn in his presentation on the relationship of research to cultural authority. He described how positive outcomes from a
NIH consensus is the authoritative blessing at the NIH. Then he led the assembled chiropractic leaders through the outcomes of a recent such consensus conference on Vitamin D and bone health.  For vitamin D, there are hundreds or even thousands of clinical trials (my notes arE not clear); for chiropractic there are 60-70 total on back pain, chiropractic's leading area of research. Yet, other than for a few conditions like rickets ("fair evidence" said Khalsa, adding: "I mean, this is Herman Melville stuff ...'), most of the conclusions were light, "inconsistent." The message: Put all your eggs in the NIH basket if you wish to have a long-shot potential of gaining cultural authority at some point after Florida is submerged by global warming,

Mathew Kowalski, DC
8.   Harvard-Osher Based Chiropractor: "Behave Your Way In"

The final panel also included the wizened integrative chiropractic commentary from
Mathew Kowalski, DC, the lead chiropractor at the integrative clinic sponsored by the Osher Clinical Center for Complementary and Integrative Medical Therapies. Before Osher, Kowalski worked in a half-dozen health system-based integrative settings, going back to 1991. He asked, rhetorically: "The biggest common denominator in all the experiences on how I got it?" He pauses: "I asked." There are 30 chiropractors credentialed into VA facilities, 49 in US Department of Defense establishments, and 180 in "civilian hospital based chiropractic practice." This totals some 260 out of 70,000 chiropractors. Why so few? Says Kowalski: "(Chiropractors) just don't ask." Most MDs, he said, have never met a chiropractor, "don't know how to use one and hospitals don't know what to do with them." His conclusion, at this time, is that most of the advances he has made are more from individual achievement than cultural authority. I don't embrace chiropractic but I like this one chiropractor. Chiropractors, says Kowalski, "need to educate [our] way in." More than that, chiropractors need to keep the patient at the center of their motivation for connecting with hospitals or medical doctors: "We need to behave our way in." That stated, Kowalski noted that the Osher position was the first in which the invitation did not come from his own initiative. Said Kowalski: "There was some cultural authority there."

Comments: This article begins and ends on the same note: relationships. A year ago at this time I was just completing some exciting work with a chiropractic organization. A colleague who is a chiropractic educator and I recommended that the group take a series of steps to support their members in developing networks of relationships with other CAM and conventional providers. The visual was a simple wheel with the chiropractor in the center, and spokes radiating out to one each: massage therapist, primary care MD/DO, AOM professional, naturopathic doctor, physical therapist, mental health/psychologist and an orthopedic surgeon. The recommendation was that the organization have an internal goal of supporting their members to each have at least one of each of these practitioners with whom he or she felt comfortable cross-referring. We said: Just explain to each that your patients want you to be connected.
Do this and you will be playing against type. Others won't expect this of chiropractors. The organization has not, to my knowledge, moved on the suggestion, or anything like it.

Image At the end of my presentation on enhancing collaboration, which began with a description of chiropractic's limbo, I used a slide with a photo of a Roy Lichtenstein painting. The blond has a telephone clutched to her right ear, her eyes are shut from fear and a tear is falling from the left eye. She is saying: "Oh no!! I can't believe I forgot to have a relationship."

Coda: Barack Obama's powerful speech on race March 18, 2008, is fresh in mind as I write this. In the healthcare integration process, it is the chiropractors who have had the harshness of the psychic stamp that, in race relations, is paralleled by the experience of slavery on the soul of the black man. The chiropractors were the chief targets of the AMA's vicious anti-quackery campaigns in the 1960s-1970s. It is the chiropractors who successfully fought the financially bloodying 12 year, David-versus-Goliath anti-trust suit against the AMA which, with the chiropractic victory, ended the worst of sanctioned, institutional medical bigotry in the United States. It was the chiropractors who asserted a place on the bus of US healthcare, and refused to move.

In truth, for most of the last century of chiropractic's existence, chiropractors were not allowed, by our culture's established medical authorities, to have a relationship with them. Chiropractic learned to go it alone, come hell or high water, developing a learned ferocity through the pattern of received abuse. Yet now that profession's destiny, it's ability to gain authority, to fully serve clients, is inextricably linked to its ability to throw off that isolation through a patterned network of ongoing, essential relationships with other healthcare stakeholders.  Secure inside that web, the gold ring of cultural authority will be in hand.

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