Stephen Bolles: Regarding a Trojan Horse with Chiropractic/Chiropractic Medicine at a Cross Roads

Summary: Chiropractic bounces around in an odd, in-between niche in US healthcare. Some 7-10% of the public regularly use chiropractors, yet the "integrative medicine" dialogue often likes to exclude them. A part of the reason may be the field's extremely challenging identity issues. A recent battles in New Mexico over a move to add prescription authority has erupted the field's simmering tension between its dual personalities, often described as "broad scope" or "straight." In this column, the always thoughtful Integrator contributor Stephen Bolles, DC, looks at the issue, and questions whether "broad scope" is a Trojan Horse that may be the field's undoing. He is an unusual commentator on the subject with many years associated with one part of the field, and more recently working closely with the other.  

Stephen Bolles, DC

Background Perspective: Chiropractic bounces around in an odd, in-between niche in US healthcare. It's a limbo profession, neither alternative nor conventional. Most insurers cover it, but for limited services and often low rates. Still, chiropractic, or chiropractic medicine as chiropractic doctors prefer to label their field - to great opposition from others - is financially a surer choice than most non-conventional disciplines. Thus, like high-paying medical specialties, chiropractic draws some who view the profession

that still dominates the life choices of many drawn to the other so-called "CAM" fields. At the same time, as the favored whipping boy by an out-of-control, domineering AMA from 1960-1990, that literally had to fight in every domain for its survival, chiropractic has some characteristics of a scarred and abused child. Chiropractors were forced to battle in the courts, ultimately successfully (as will be featured in the upcoming documentary Doctored) to keep the behemoth of the AMA from exercising illegal restraint of trade. Chiropractic, as a profession, has been forged and fractured in some very nasty internal and external fires.

The Big Split: One split that this history has wrought relates to a subset I recently called "broad-scope" in an Integrator article. This version of chiropractic is a form of integrative medicine that may include a broad array of whole person techniques. These can include supplements and acupuncture (which some chiropractic colleges first brought into formal health professional education in the United States) and lifestyle coaching. The "broad scope" chiropractors, many of whom favor the use of "medicine" in describing what they do, are counterpoised to the so-called "straights" who, often with a religious fervor, seek to ban such language. The latter not only do not view chiropractic as "medicine," they are adamantly opposed to the two words - chiropractic medicine - ever being linked. Their practices are based on vitalism and the theory of the subluxation and the practices on spinal manipulation. Their associated schools are less likely to be involved in NCCAM-funded research and their academic leaders less drawn to the "integration" dialogue. 

Urges state self-determination on scope

Recently the differences have roiled upward as the broad scope supported moved in New Mexico last year (see below) to stake out the right to prescription authority, attached to specific additional training. This would open the door more widely to a stronger claim for this subset of the profession to a significant role in helping meet the nation's primary care needs. I used the "broad scope" term in an article on  this effort which provoked the thoughtful column from Stephen Bolles, DC, below. This in turn sparked additional exchange which has been appended below. 

About the contributor/author Stephen Bolles, DC: Stephen Bolles is a Minnesota-based chiropractor by training who has had multiple roles over nearly three decades in health care: practicing chiropractor, a leader in Minnesota chiropractic politics, vice president and integrative clinic developer at Northwestern Health Sciences University (including roles in two significant health system-based integrative clinics), consumer expert and business product developer at UnitedHealth, and more recently, entrepreneur and strategic project manager at LIFE University, a leader among the "straights." Among the projects he's shepherded are human resources performance processes, the LIFE Octagon think tank project, and LIFE's Wellness Portfolio initiative. Bolles past contributions to the Integrator includes this re-write of 8 trends in the integrative health industry.

Bolles' comments are interesting in particular because, as he says, he comes from a part of the profession (Northwestern) that is closer to "broad scope" yet is questioning that term.

Some months ago I sent you a note about a description you posted early this year wherein you used the term 'broad scope chiropractors.' (See this American Chiropractic Association House of Delegates chastises sin the March 2012 Integrator Round-up.) There were so many inherent values and considerations in the term that I found myself trying to frame a perspective on it. It may sound like a provincial concern to those outside the chiropractic profession. Perhaps it is. But as the health care marketplace begins to revise what services are available, at what cost, from which profession(s), what the consuming public infers from such descriptions will come to matter in a big way.

"The chiropractic profession is struggling with the challenge of attempting to ensure its services are and remain available to a rapidly changing marketplace. At the same time, its very sense of what those services should be is not something that the profession as a whole agrees on."

The term 'broad scope chiropractors' in your interesting post conveyed a specific way of describing a segment of the profession. At the same time, I found it kind of jarring. So I thought I'd drop a note and see what your thoughts about this issue are. As you are well aware, the chiropractic profession is struggling with the challenge of attempting to ensure its services are and remain available to a rapidly changing marketplace. At the same time, its very sense of what those services should be is not something that the profession as a whole agrees on.

The issue is one of identity, and the impact on the profession of any term that offers a structure for that identity to the exclusion of others within the profession. For example, there is one sort of impact in the consideration of whether or not a modality (such as electric muscle stimulation) should be used to complement an adjustment.  A very different impact is created in the consideration of seeking and securing prescription privileges. For me, the question of 'what is chiropractic?' is far more central in the consideration of prescription privileges than to that of a supplemental modality. 

It's a very provocative issue; some are pursuing a broadening of scope that assimilates prescriptive privileges; others see this as a threat to the central professional identity. Part of the issue for us as a profession is that the very terms of the challenge are difficult to reconcile: one segment sees it as a scope issue (application of identity), while quite another sees it distinctly and purely as an identity issue, independent of scope. It's polarizing for us, and has unfortunately cast the dispute into 'winners' and 'losers:' because we're not able to reconcile it through discourse, we're retiring to the legislative arena to duke it out.

	"Some are pursuing a broadening of scope that assimilates prescriptive privileges; others see this as a threat to the central professional identity... The two perspectives are clearly not the same, and this issue can fracture this dynamic and easily-polarized profession."

The two perspectives are clearly not the same, and this issue can fracture this dynamic and easily-polarized profession. The segment that argues in favor of prescription privileges holds that they would be an enhancement to the therapeutic armamentarium of doctors of chiropractic. Seems to make sense, right? It would, essentially, broaden the applicability of a visit to a DC in the public's mind. Medicine becomes a therapy. There's a lot to like in anything that diminishes the prominence of medicines as relevant tools in health care; this was underscored recently by the Georgia Attorney General citing prescription drug abuse as a significant problem.

It's not that simple, though, and I feel extremely strongly that the seeming benefit in the 'diversification-enhancement' argument is actually a loss. Why? Because the paradigm central to the profession's identity focuses on optimal neurologic function. Prescription medicines address symptoms, and if someone is feeling better because of drugs and not in touch with diminished function, it's easy to overlook the problem. For providers, adding prescriptive privileges also introduces the seduction and and ease of demoting the importance of the contribution adjustments have to offer. The effect is one of shifting the paradigm to a medical model where the choice is between adjustments and medicine as therapies, falsely representing a type of equality in effect, when just the opposite is true. Worse, it essentially creates a position for the profession where it becomes an accomplice to the US health system's greatest level of dysfunction: that people feeling symptoms go and get a pill to feel better, rather than dealing with the underlying problems. And arguments that stress those contact moments as opportunities for educating people about chiropractic and the real cause of diseases don't cut it for me, because the American consuming public too often wants the easy way out. If scope laws change to include limited prescription privileges, I believe the 'tiering' of the profession in terms of what a consumer/patient finds available to them when they enter a doctor's office will confuse the marketplace in a corrosive way.

On DCs Seeking Prescriptive Authority "It essentially creates a position for the profession where it becomes an accomplice to the US health  system's greatest level of dysfunction: that people feeling symptoms go and get a pill to feel better, rather than dealing with the underlying problems."

Who's right? Both have truth on their side, but in different proportions. But the reason I'm writing this is that the terms used convey and imply value judgements, and those reinforce perceptions. "Broad scope" makes it sound like it's a bigger, more inclusive tent. Ain't necessarily so. Coming as I have from the 'side' of the profession that is more comfortable with a broader therapeutic toolbox, I can see the value of a bigger toolbox--up to a point. But through my work with LIFE University over the last five years, I have also come to see things quite a bit differently: that there is a core identity issue at stake, and it hinges on answering the challenging question: what is chiropractic, and what is not? The 'broad scope' DCs can be seen, in one way, as assimilating therapeutics that diversify their value in the marketplace. That sounds pretty benign, on the surface. I do think, though, at this point in my career that this is a mistake, and conveniently avoids the problem that's been created by our inability and frustrated attempts to describe just what our value is. With the judgement of the marketplace in hand--and my arm's tired from pointing to the fact that only 7-10% of US adults use chiropractic--I'm not convinced that adding therapeutics that further confuse the marketplace about what a chiropractor 'is' solves much. And I can make the argument that the fuzzier professional identity may even erode the marketplace penetration we've accomplished. Chiropractic isn't medicine. "Chiropractic medicine" is an oxymoron.

	Chiropractic 'is' chiropractic. It's not medicine. 'Broad scope' is not simply a term of including possibilities; it's also potentially a Trojan horse.

For me, the most appealing alternative is to figure out what 'integration' means for the profession. It is decidedly not a loss of identity or dilution of our philosophy, but just the opposite. One of the things I'm working on with LIFE is to frame solutions for all this so that integration can be legitimately seen as an option, a way to strengthen the identity and position of the profession and not trade anything off. That becomes possible in a set of professional relationships and clinical algorithms that preserve and use to patients' advantage clear and distinct professional roles and boundaries. The conversations that have been taking place at the LIFE Octagon have laid a good foundation for that coming true.

I don't know whether Naturopathy has gone through the same angst about its identity in its moves toward limited prescription privileges. If it has and the issue has been resolved to the satisfaction of the majority or whole, good for them. We're still challenged by the issue. Osteopathy made its choice quite a while ago. And while it's my wish that a discussion about how our profession uses language like this could help expose some of the dangers of our current direction, I don't see that happening. So I appreciate the chance to draw your attention to the problem. Chiropractic 'is' chiropractic. It's not medicine. 'Broad scope' is not simply a term of including possibilities; it's also potentially a Trojan horse.

Bolles again, on the battle over chiropractic prescriptive authority

"Indeed. This is a case in point on what we just corresponded about. NM was poised to change chiropractic scope to include prescription privileges, and at literally the 11th hour, a few DCs came in and worked to disband the agreement that was in place between the NM Board and the Legislature. It was, however, a short-term fix, and it inflamed both sides.

"For many involved it was a legislative 'fight to the death' for what they regard as the soul of chiropractic."

"For many involved it was a legislative 'fight to the death' for what they regard as the soul of chiropractic. Turn one way, DCs become (in their view) physician extenders and lose their soul; turn the other way and DCs become (again in their view) a more mainstream health provider 'citizen of the system.' 

"I was pretty conflicted about it for a short time, but thinking it through forced me to decide which view I held to be more true. And that led to the thinking I reflected in my recent note to you.

"The fight's not over. I'm told other states are likely to succeed in moving in this direction. Once they do, I'm afraid that the profession's lot may have been cast, and not for the better.

"As a result, the argument can be made that the American version of chiropractic won't be able to avoid ultimately become medical. Attention is now turning to determining what the profession's identity--and supporting scope--will be overseas. There's a major philosophic and developing legal battle being fought in Europe about this right now, and it's going to become an issue in Asia as well. Africa is probably quite far away from being anything like what's going on elsewhere.

	" ... unless I've misread cultural and social anthropology examples, I predict that the direction [toward prescriptive authority] will result in a profound loss, one that will be regretted later with only a weak residual form of the earlier identity available for recovery (see Osteopathy)."

"So what changes all this? Good question. I think it goes back to the cultural authority issue. I believe we have not established cultural authority because we do not have a clear cultural identity. Those who advocate for identity 'evolution' are, in effect, asserting that the medical culture is the bigger tent that can hold all this, and are dismissive of what is forsworn by that direction. But unless I've misread cultural and social anthropology examples, I predict that the direction will result in a profound loss, one that will be regretted later with only a weak residual form of the earlier identity available for recovery (see Osteopathy). 

"Interesting times. The ACA taking a position to defend the right of self determination of the Board is quite different than defending the same right of the profession. The Board is regulatory, not representative. A regulatory role protecting the public is pretty far removed from stewardship of professional identity and application.

Comment: In a world in which "my way or the highway" is causing all kinds of war, famine and death, I lean heavily toward the more distributive, states-rights position of the ACA. Different states can pursue different scopes. The fundamentalism in dictating that there is just one way is troubling.

At the same time, the audacity of the non-broad-scope chiropractors to declare that chiropractic is about "health" rather than medicine is refreshing, simply in its radicalism. We'll be in good shape when all "broad scope" professions are working together, not reactively, but at creating health in the individuals and populations they serve.

The Trojan Horse image in not without its merits. That access to magic bullets tends to lead to more use of magic bullets would appear to be proved in spades in the real world experiment called osteopathic medicine. The old-time naturopathic statutes from the 1950s and 1960s in states like Florida and Utah where naturopathic doctors had broad prescription rights also tended to produce a great deal of "back door allopathy." Is there research on the impact of broadening prescription rights on the modern naturopathic medical profession's clinical norms? The tendency to use what gives the quickest response seems to be linked, unfortunately, to human nature. Maintaining a Jeffersonian barrier to protect one against taking an easy route that may be less salugenic (e.g., putting up a barrier to prescriptive authority)