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Comments Forum: Chiropractic, CAM and "Cultural Authority" PDF Print E-mail
Written by John Weeks   

Comments Forum: 5 Voices on Chiropractic, CAM and "Cultural Authority"

Summary: My reflections on the theme of "cultural authority," with which the chiropractic profession is wrestling - in its relationship both to conventional medicine and the "CAM"- stimulated a half-dozen thoughtful responses. Stephen Perle, DC, MD, focuses on the idea of chiropractic as a "limbo profession." James Winterstein, DC, wonders if naturopathic medicine and acupuncture and Oriental medicine are easier for conventional medicine to embrace because their more unusual theories are less known. William Wulsin, ND, LAc, MPH (cand.) offers a historic, and hopeful perspective. Lou Sportelli, DC, muses on how a person's positive experience of a chiropractor will not necessarily translate into positive views of chiropractic. Finally, Stephen Bolles, DC, concludes some forthright commentary with a view that "perhaps cultural integrity and (forgive me) authenticity require some serious attention at this point in our development." Excellent perspectives with resonance for all emerging fields.
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On March 14-15, 2008, I attended the annual Association of Chiropractic Colleges and Research Agenda Conference (ACC-RAC), the major annual gathering of educators and researchers involved with chiropractic. The Integrator article on the gathering, Reflections on Cultural Authority, CAM and Chiropractic from the 2008 ACC-RAC, March 20, 2008., stimulated a handful of thoughtful responses. The themes have a variety of resonances for all of the complementary and integrative medicine fields. To what extent is association with complementary and alternative medicine (CAM) a liability?


1.   Stephen Perle, DC, MS: "chiropractors fit in two distinct paradigms"


Stephen Perle, DC, MS is a professor of clinical sciences at the University of Bridgeport and a well-known columnist and speaker in chiropractic. This is his first time commenting in the Integrator.

"egarding the blog on ACC/RAC; I think the issue of embracing or eschewing CAM is very important for chiropractic and there are significant points in favor of each position.

"As Tony Rosner [PhD, a leading researcher in the field] pointed out to the World Federation of Chiropractic a few years ago, disavowing any association with CAM could put us in the position of not having any sources of federal money for research and infrastructure construction. [NCCAM staffer] Partap Khalsa, DC noted that there are grants at NCCAM that one can only get if one has a DC, ND or DO (if doing manipulation). Hence, a complete repudiation of any association with CAM is NIH financial suicide just as complete repudiation of any association with the subluxation is Medicare financial suicide.  Of course, I believe that the subluxation is an albatross around the profession’s collective necks.  It carries too much baggage and has not been demonstrated to exist. (1)

   
  "On the other hand, CAM
carries baggage that is a
barrier to receiving a
significant source of referrals
from the mainstream.
"

-  Stephen Perle, DC, MS
 
"On the other hand, CAM carries baggage that is a barrier to receiving a significant source of referrals from the mainstream.  But to show that everything is a two edged sword a friend of mine was the chiropractor at a hospital-based integrative clinic.  He was dumped in part because he did not burn incense, chant and pour essential oils on his patients.  So in one place one is too weird as a CAM provider and in another one is too…not weird.  Thus, what gets one is one door will get the door slammed in ones face in another venue and visa versa. Can’t win for loosing. 

"Then again I think Astin’s paper explains much about why people come to chiropractors IF we are CAM providers.(2)  I think despite Kuhn’s assertion that paradigms are mutually exclusive chiropractors fit firmly in two distinct paradigms CAM and mainstream healthcare. And I believe that we can do so comfortably depending upon the demands of both camps. That is because I think neither CAM nor conventional health care are the overarching pinnacle of the healthcare paradigm. They are just smaller sub-paradigms within a supreme paradigm of the Hippocratic paradigm: Ωφελειν η μη βλαπτειν  "to help, or at least to do no harm" taken from Hippocrates’ book Epidemics, Bk. I, Sect. XI."

Stephen Perle, DC, MS
University of Bridgeport
www.bridgeport.edu/~perle
Ethics Articles www.chiroweb.com/columnist/perle

1. Keating JC, Jr., Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF. Subluxation: dogma or science? Chiropr Osteopat. 2005 Aug 10;13:17.

2. Astin JA. Why patients use alternative medicine: results of a national study. Jama. 1998;279(19):1548-53.

Image
Jim Winterstein, DC
2. Jim Winterstein, DC:


Jim Winterstein, DC
, president of the multidisciplinary National University of Health Sciences (chiropractic, acupuncture and oriental medicine, naturopathic medicine) responded to my query about his take on the "cultural authority" piece.
"I liked your piece. Interesting how it works. I think naturopathic medicine and oriental medicine are still sexy – something that is long gone for chiropractic and of course, the baggage characterized by old time chiropractic dogma really works against us in my opinion. The powers that be have not yet figured those things out about naturopathic medicine and the others. Think of the weird concepts of 5 element theory in acupuncture – but that seems to be overlooked in favor of a “biomedical” concept of acupuncture. Meanwhile, we must keep right on slugging!"

Jim Winterstein, DC
National University of Health Sciences

Image
William Wulsin, ND, LAc, MPH (cand.)
3.    William Wulsin, ND, LAc: "'CAM' doesn't describe any common ground ..."


William Wulsin, ND, LAc, MPH (cand.)
has worked in integrative public health clinics, at Bastyr University, in international health projects and in a Seattle private practice. The last time he commented in the Integrator was on the subject of whether NDs should refer to their education as "medical school" (November 23, 2007).

"Excellent survey of issues pertaining to 'cultural authority' in the chiropractic world of healthcare.  The idea of culture seems key to me for every profession that offers health services. Each one has its own culture defined by the collective experiences of patients and practitioners alike. It is not difficult to sense the differences: at the schools, in the offices/clinics, in the yellow pages, and most saliently in relationships.  Perhaps the CAM label is beginning to lose its usefulness, as its diverse healing disciplines become more securely instituted in their identity and validity regarding the perspectives of science and the marketplace.

"Chiropractic has a rich and colorful history that predates the AMA dominant era.  They withstood the post WW2 wave of opposition from the major medical powers after the DO's joined ranks and the naturos largely went underground.  Like classical homeopaths, they do not share the parentage of societal exploration and rebellion that invigorated Euro-centric exploration into TCM, massage therapy, yoga, transpersonal psychology and modern naturopathy. We do share roots however. The same ones that all healers possess once they have discovered a practice that works for themselves and their patients.

"We may indulge in different colors, foods, incomes, clubs, priorities or politics, but at the heart we function similarly.  Somehow the notion of CAM does not describe any common ground and I doubt that was ever the intention. Turf wars will likely never become obsolete, but their frequency and intensity may calm down with a more secure status quo among all flavors of healthcare provider."

William Wulsin, ND, LAc, MOH (cand.)
Seattle, Washington

Image
Lou Sportelli, DC
4.    Lou Sportelli, DC: "the exact reverse model exists in chiropractic than medicine"


Lou Sportelli, DC, is a 40+ year observer of his profession's dance with "cultural authority," as practitioner, professional association leader, as president of the leading malpractice insurer, NCMIC, an Integrator sponsor, and as an explorer in the emerging "integrative medicine" field.
"What an excellent overview of the cultural authority issue.  The exact reverse model exists in chiropractic that exists in medicine.  In medicine you have cultural authority collectively, simply by being an MD not because you did anything to earn it,  and each individual MD has the opportunity to retain it , expand upon it, or loose it.  The chiropractor has no collective cultural authority simply because he/she is a doctor of chiropractic.  They each earn their individual cultural authority one DC and one community at a time.  Here the DC either enhances it and creates relationships which expand the cultural authority into other areas such as what Dr. Kowalski has done.

   
"The exact reverse model
exists in chiropractic that
exists in medicine.  In
medicine you have cultural
authority collectively, simply
by being an MD not because
you did anything to earn it, 
and each individual MD has
the opportunity to retain it,
expand upon it, or loose it. 
The chiropractor has no
collective cultural authority s
imply because he/she is a
doctor of chiropractic.

- Lou Sportelli, DC

 
"There are issues and naturally the chiropractic community is still bruised from the long history of prejudice and bias of the medical community.  In the words of Judge Getzander who said it so eloquently, 'the lingering effects of this boycott will be felt for generations' and it has taken time, and the profession, as most things, will advance one funeral at a time. 

"The chiropractic profession has continued to evolve, has a cadre of young researchers and a body of scientific evidence to support some of the hypothesis which are fostered by the profession.  The individual practitioners each play a major role in the evolution of cultural authority because in today's 'media driven world' the actions and antics of a DC anywhere in the country is immediately broadcast locally as well as nationally and with the U-tube maintaining the data in perpetuity, there is little hope of anonymity. The awareness of how significant cultural authority is, cannot be overstated.  The chiropractic profession has done a marvelous job, in light of the obstacles which confronted it, and as Clem Bezold stated once as a futurist:  'If something lasts 100 years we take a look at it.'  Well, chiropractic has passed the 100 year test and we are now moving toward a recognition by a new group of health care consumers (the baby boomers) who changed the world in the 60's and will do it again in the 21st century
."
 
Lou Sportelli, DC, President
NCMIC Group

5.    Stephen Bolles, DC:
"chiropractic has never gotten  over a 'bastard child' complex"

Stephen Bolles, DC has held positions as vice president with the Northwestern Health Sciences University, and as a consumer healthcare leader with United Health. He currently consults in chiropractic education and integration strategies.

"Enjoyed your post about ACC-RAC. I'm currently doing some work for Life University. My time at UnitedHealth radicalized me as to what CAM professions (as well as medicine) are NOT doing to prepare for the emerging 'retail health care marketplace' and has markedly influenced my perspective and my work as a consultant since that time.

   
 
"I hope-but am doubtful-
that cultural authority
will be much of a
change agent."

- Stephen Bolles, DC


"Your post was thought provoking, for a number of reasons. I hope-but am doubtful-that cultural authority will be much of a change agent. I've got a sense that the possible convergence points for trends around evidence-based medicine (whatever the hell that really means), increasing economic independence as it pertains to decisions about consuming health services (health savings/reimbursement accounts, etc.), lack of imagination on the part of health plans, emergence of employers as 'the' true consumer/decision-makers about health plan products, and the waning economic benefits of network management on the part of health plans, all lead to a set of points where the end game may be such that cultural authority doesn't matter much.

"I agree with your designation of chiropractic being a 'limbo profession.' It's my belief that in many ways we've never gotten over a kind of 'bastard child' complex, and for very understandable reasons have a pretty defensive attitude about our practices and the level of acceptance. Our internal squabbles about who's right, who's wrong and who owns the real mantle of D.D. Palmer has been enormously destructive and corrosive--mainly to ourselves. Our legislative strategies have been generally effective so far in keeping competitors at bay, but it's my minority view that this strategy is self-limiting and doomed to eventual failure without some seriously introspective and hard work to tighten up our own standards and decide just what it is we want to be when we grow up. As I try to point out over and over: after 113 years of 'operations,' we've got perhaps 7% of market penetration. That's not the mark of a successful business strategy.

"There are decidedly some good and important efforts going on. I think some of the things being done by the groups represented at ACC-RAC are a great case in point. I only hope that as a profession we can move with the urgency I believe the situation requires. I don't know that I see that at this time.

   
"I think that perhaps where
we missed the boat most
seriously was when
chiropractic failed to
mobilize to address the
opportunity Clem [Bezold's]
group teed up so beautifully
in the IAF's report on
chiropractic back in
the mid-1990's."

- Bolles
 

 
"I think that perhaps where we missed the boat most seriously was when chiropractic failed to mobilize to address the opportunity Clem' [Bezold's] group teed up so beautifully in the IAF's report on chiropractic back in the mid-1990's. Then and again when they revisited the issue several years ago, the market opportunity for chiropractic was as clearly detailed as we could ever want it to be. But due to, in my view, an abject failure in our leadership, we let the boat sail. And as our brothers and sisters in other healing professions become our competitors in a more market-driven dynamic (where 'demand' may yet dictate to 'supply' what products are delivered), we are seeing the window close. It's not a happy day. At the same time, the inroads in some areas are notable. I just worry that it's too little, too late.

"Many disagree with me on this, and that's fine. We have an enormous opportunity; it's just that as the marketplace we operate in changes under our feet in a direction we have not anticipated or planned for, it is going to take more and more effort to respond in any effective manner as time goes on. I have subscribed for a long time to the thought that cultural authority mattered tremendously, and that relationship-building was the key to bridging interprofessional/intercultural differences. But cultural authority depends on a coherent system that I don't know we can point to. Our one profession is, perhaps, more like two suspicious tribes trying to co-exist, placed more and more into oppositional roles as the natural resources we depend on shrink around us. Rather than take a sober, clear-eyed view of the challenge, it's easier to focus our frustration and wrath on those we know and partially understand.

"At the chiropractic group tasked with CAM strategies at a national chiropractic legislative conference about six years ago I argued for exactly what you were aiming at with the group of practice-oriented DCs. I proposed a position that was profoundly at the base for the strategy we used in moving NWHSU from a chiropractic college to, hopefully, a bigger sandbox where many could play and not fight over the toys. That position was simply that we can solve problems with friends much more simply than we can solve problems with competitors, and the black/white perspective that helped us survive politically for years (as in fights with the AMA) was dated, inaccurate, self-limiting and even dangerous as a basis for continuing. It fell on a set of hard, deaf ears there as well.

   
 
 "[My] position was simply that
we can solve problems with
friends much more simply than
we can solve problems with
competitors, and the black/
white perspective that helped
us survive politically for years
(as in fights with the AMA)
was dated, inaccurate, self-
limiting and even dangerous
as a basis for continuing. [My
argument fell on a set of hard,
deaf ears there as well."

- Bolles

"I also do not think that research findings are going to vindicate our professional assertions; nor are they likely, in my view, to provide much leverage in improving 'the system's' response to us. At the end of the day, I don't think the system is going to love us any more, nor pay us any more equitably, nor include us in any way we have sought for generations. The system itself is under too much pressure and changing too fast, and that moving target is one we as a profession do not even see. Research data are wonderful, but we don't have enough time, money, or even perhaps the paradigm right for understanding what it is we're even trying to measure. Extracting elements of the profession's approach and subjecting them to the rigors of medical research protocols may be producing accurate information; it may also be skewing results in ways we do not comprehend, but then use to shape our practices and education. It's as if we've been sold on having to buy a ticket to the dance, but end up wondering if we even should have come.

"So what is the answer? I think that Mathew Kowalski has at least a piece of it right. Rather than 'behaving our way in,' though, I think we need to figure out just how to behave. Period. If we cannot agree on our own cultural rubric and bring our own petulant and self-entitled children to toe that line, we are not very likely to enjoy much more acceptance. Being legends in our own minds is great for self-satisfaction, but not much more.

"I would submit that perhaps cultural integrity and (forgive me) authenticity require some serious attention at this point in our development. Without it, I am afraid that those who are seriously trying to make some changes and trying to do the right thing will find a market share that dangerously begins to shrink.

"I think it's great they invited you. I hope that your message gains some traction."

Stephen Bolles, DC
Minneapolis, MN
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