Climate change: global challenges for the chiropractic profession

Richard Brown, DC, LL.M, FRCC^*

Introduction

History affords us numerous examples of circumstances where those fighting on the same side have conspired to harm each other, even to inflict mortal damage. This tendency has displayed itself throughout the history of the chiropractic profession, with disagreements over philosophy and nomenclature dominating the agenda¹ whilst external detractors have looked on with the smug satisfaction of knowing that internal tensions are perpetuating division and stunting growth².

In an era of health system transformation it is clear that the climate is changing.³ Just as western society has gradually realised the impact of global ecological change and has adapted its behaviour accordingly, so must we as chiropractors realise that the healthcare environment is changing. While this presents challenges, it also gifts us unprecedented opportunities to evolve. What is essential is that we accept that climate change is happening and commit ourselves to bravely tackling the issues before us.

Identity

I have consistently argued that for the profession to progress and be a key player in modern healthcare systems, it must jettison some of the historical baggage that has weighed it down over decades and commit itself to modern, evidence-based, research driven healthcare.⁴

This does not of course mean that chiropractic should suddenly turn its back on the philosophies and practice that has shaped its development and assured its survival since 1895. The power of the spinal adjustment, the consideration that the integrity of the spine has a direct impact on human health and the view that as living organisms we are more than simply the sum of our parts have all been guiding principles. However, the language in which we cloak our profession often suggests an archaic mindset and a refusal to move away from pseudo-religious concepts often embraced by complementary and alternative medical practices.

It is therefore of paramount importance that the chiropractic profession agrees a universal identity which is consistent around the world. Back in 2005, the WFC published the results of its identity consultation.⁵ At this time, it was decided that the most appropriate public identity for the chiropractic profession was that they should be the spinal healthcare experts in the healthcare system. This was the result of two years of intensive work including a grass roots electronic survey of chiropractors worldwide.

It is widely considered that are seven pillars upon which chiropractic’s identity should be grounded.

1. An ability to improve function in the neuromusculoskeletal system and have a distinct impact on the overall health, wellbeing and quality of life.

2. A specialised approach to examination, diagnosis and treatment which must be based on the best available research and clinical evidence, with a particular emphasis on the relationship between the spine and the nervous system.

3. A tradition of effectiveness and patient satisfaction.

4. An avoidance of drugs or surgery, enabling patients to avoid these where possible.

5. Expertly qualified providers of spinal adjustment, manipulation and other manual treatments, exercise instruction and patient education.

6. Collaboration with other health professionals

7. A patient-centred and biopsychosocial approach, emphasising the mind-body relationship in health, the self-healing powers of the body and individuals’ responsibility for health and encouraging patient interdependence.

Late in 2012, Palmer College released its own identity statement.⁶ This had many similarities with the WFC 2005 statement, positioning chiropractors as the primary health care professionals for spinal health and well being.

The synchronisation of identity statements from two of the world’s leading organisations must surely gift us the opportunity to create a global message for the consumers and potential consumers of spinal health care services. Now is the time to bring together educators, academics, researchers and clinicians to finally agree how chiropractic should be portrayed to the world.

Education

While we gladly accept that education in any discipline may be delivered in a range of formats, with differing emphases on individual components, there are inevitable boundaries. Inspectorates of schools, prisons and other state institutions ensure that minimum standards of education are attained, which correspond to nationally agreed frameworks. In medicine and dentistry, despite different emphasis on delivery (traditional didactic learning versus problem-based learning, for example) there is a broad consensus when it comes to required levels of competency and professional standards.

However, the evolution of the chiropractic profession, historically characterised by private educational institutions, has meant that a largely self-regulating mechanism has prevailed. The various Councils on Chiropractic Education have set their own accreditation criteria⁷, but flexibility of interpretation has meant that the delivery of chiropractic education between institutions remains startlingly different. While some focus on a strictly science-based and biomedical model, others steer their students towards more philosophical tenets.

Within the chiropractic profession many celebrate the diversity of educational approaches in chiropractic, lauding it as being symbolic of the various strands of development that have woven their way into the fabric of our profession. At the same time, others bemoan the fact the disparity and differences between programmes of study have created an indistinct image of chiropractic education, one where examples of excellence are interspersed with less robust programmes of study. The long term survival of chiropractic education outside the mainstream university network appears in some regions uncertain and this has been reflected in declining student numbers.

There may be a number of factors at play. The costs of education and training are such that in a global recession, they may have become prohibitively expensive. Opportunities for graduates may be more limited. Adverse media coverage and tarnished reputations of the profession in some areas may have reduced the demand for chiropractic. But perhaps one of the biggest challenges to the profession is that other manual therapy professions have realised the market for skilled spine care services and have focused their attention on what is seen as a vast untapped market.

The harmonisation of education throughout the world must surely, therefore, be one of the goals of the chiropractic profession. As the world demands evidence-based, research driven healthcare⁸, there can no longer be a place where historical concepts are portrayed as fact and where students are expected to swear an undying allegiance to the theories of yesteryear.

I am not calling for every chiropractic centre of learning to become clones of one another; it is crucially important that schools, colleges and universities providing chiropractic education retain their own identity. However, in order to facilitate and foster information exchange, harmonisation of procedures and policies and attainment of comparable qualifications, there must be a robust review of the acceptability of programmes in the context of modern educational frameworks if they are to be deemed acceptable within the wider healthcare community.

In tandem with this, we must also see an expansion of the numbers of available programmes of study. The growth of the chiropractic profession materially depends upon the number of its practitioners being represented in adequate numbers over the face of the globe. We must not, therefore, be afraid of adopting new approaches to growing chiropractic in areas that are under-represented.

Research

It is often said that research is the currency of the profession. For the profession to compete and attain the cultural authority it strives to achieve, it is essential that there is an international commitment to research. This should first examine what we do primarily as chiropractors – spine-based care using manipulation – as well as the other components that make up a modern chiropractor’s package of care: supervised and home based exercise, spinal stabilization programmes, medical acupuncture and soft tissue techniques.

We must become the default spinal care experts and to be so we must be active – and be seen to be active – in the field of spinal research. Canada is one of the world leaders in grasping the nettle of spinal research and committing funds to it. The production of clinical guidelines⁹, the funding of Research Chairs and the willingness to collaborate with other stakeholders, both within the outside the profession, demonstrate clear leadership. World class chiropractic researchers are being heard and respected within forums that our ancestors would never have considered possible.

Following leads set by Canada and Denmark, other chiropractic research organisations are now appearing in Europe. The UK, Norway, Sweden and France have all now set up their own national research organisations, but in every nation where chiropractic exists we need to be sure that data is collected and the knowledge base is widened. We need to know how chiropractic care may impact on Africans, on Asians and Middle Eastern populations as well as in our own well-developed North American and European regions.

In a challenging environment where funds for chiropractic are limited, priorities need to be identified to ensure maximum effectiveness and utilisation of outcomes. Collaborations may provide an excellent platform for developing international research and ongoing work is being done to develop the North Atlantic Research Collaboration. This is an affiliation of the national associations of the UK, Canada, Denmark, Norway, Switzerland and Sweden and it is hoped that a shared research agenda between the parties will facilitate knowledge that will enhance service delivery and mainstream integration.

With enormous costs associated with sickness absence¹⁰, demonstrating chiropractic’s role in the prevention of occupational injuries and disability carries huge potential societal and economic advantage. Research directed at preventative care for specific and general populations also feeds into the health policies of many developed and developing nations.

Cost effectiveness will undoubtedly be the driver in terms of chiropractic’s role in health systems. Politicians can make all the right noises about how concerned they are about clinical effectiveness and life saving care, but the bottom line is how much it will all cost and where the best deals are to be had. Anything that shows that chiropractic is cheaper than the competition will attract the attention of key decision-makers. Reduced costs, reduced waiting times, and the satisfaction of patients, who of course are those who elect politicians to office, will get chiropractic noticed in the healthcare marketplace.

Widening access

In developing the chiropractic profession, we must constantly endeavour to widen access to care beyond those who can afford it. If we are to become the spinal health and wellbeing experts, we must strive to ensure that the services that we offer are available to everyone in society.

Widening access to care will increase the exposure of chiropractic to groups otherwise unable to benefit from what we as healthcare professionals can offer. This is relevant not only here in Canada on a socioeconomic level, but also internationally, and initiatives by Scott Haldeman and World Spine Care in Botswana and India as well as humanitarian missions to disaster zones and other developing areas of the world have helped to illustrate the compassionate nature of chiropractors in the delivery of healthcare.

On a local level, the involvement of chiropractic organisations in public health must be prioritised. As neuromusculoskeletal experts, governments, organisations and society expect chiropractors to be active in the field of public health. Here, there is of course no instantaneous reward; no queues of patients starting to form in an orderly fashion outside chiropractors’ offices and no dramatic upturn in terms of universal acceptance. However, what engagement in public health initiatives achieves is authority through altruism.

The identification of back pain as the single leading cause of disability worldwide, with MSK disorders as a group being the second greatest cause after cardiovascular conditions, should propel us all to become involved in health promotion. The Lancet’s December report¹¹, supported by the WHO, should be a clarion call to the chiropractic profession to take ownership of the responsibility to educate populations in the area of spinal health.

Whether it be safer lifting campaigns, perfect posture initiatives or spinal exercise drives, chiropractors should be at the forefront of any and all spinal health education. If we are to satisfy the weight of expectation that society will place on us as experts, we must address that expectation, not just by the effectiveness of our adjustments or diagnostic techniques, but by showing that we have a concern for health prevention strategies. Again, this is something that should be the product of effective leadership and strong collaboration. The Straighten Up and Just Keep Walking campaigns are examples of excellent work but we must dedicate funds and energy to ensuring that with the opportunities before us chiropractic is positioned as a public health leader in enhancing and improving the health of our nations.

Policy input and research

As a profession, it is imperative that we not only reach the spines of the public, but also the minds of our politicians. Engagement in health policy and involvement in helping to steer the direction of health transformation is vital if we are to secure recognition and credibility. In the changing climate of health systems, the challenge for the chiropractic profession is to have a voice on matters of policy and decision making, particularly in the field of neuromusculoskeletal care.

This is largely a factor of resource allocation and political knowledge. The lack of formal regulation in many nations makes Government links difficult to forge and the relative immaturity of the profession in certain regions makes inroads a distinct challenge. With opportunities opening up in the brave new world of modern healthcare, it may therefore be relevant for future international congresses to consider sharing knowledge and skills in the fields of lobbying and political networking.

Developing leadership skills

The outdated view of leadership are that leaders are marked out for greatness from an early age and that if you are not a born leader, there is little that you can do to become one. The persistence of this view in some quarters is a great pity, but the modern view, and one that I wholeheartedly support, is that with perseverance, determination, passion and hard work, anyone can become an effective leader.

But leadership in chiropractic seems to be something that, certainly when I was a student, was missing from the curriculum. We were taught to assess, diagnose, adjust, x-ray and write reports, all essential attributes in clinical practice, but we were not given any advice on how to be leaders.

Of course, it might be argued that to teach leadership is not the responsibility of the educational institutions, and they may be right. Their role is to produce safe, competent, confident graduates. So whose role is it to ensure that there is a legacy of effective and strong leadership that is passed on to future generations of chiropractors?

The truth is that probably we all have a duty to communicate leadership. We must display strength during periods of adversity and humility during periods of celebration. We must have a vision for the future and turn that vision into a reality. And we must have a passion for what we do such that we may get up early and go to bed late, we stay excited about what we do, we see potential in others and be thrilled when they succeed.

I believe that there is scope for a leadership programme in chiropractic. This can be organised on a regional, national or global level but its essence must be that we can be assured of strong, committed leadership to develop the profession worldwide. This calls for investment, both financially and in time, but such an investment will be rewarded many times over. Guidance, mentoring and stewardship should be as much a feature of graduate development as practice management. We are not all destined to become leaders of national or Provincial organisations, but every graduate chiropractor will be need leadership skills as they navigate their way through the intricate windings of their careers as clinicians, clinic owners and beyond.

Strategy

In light of the changing climate in healthcare what should be our key strategies to overcoming the challenges that lay before us? Strategy is all about shaping the future and for us as chiropractors we must develop a strategy that is future focused and looks at the unmet needs of patients and society. The area of spinal health is a vast, largely untapped and currently mismanaged global burden but for chiropractic to seize opportunities it must carefully plan its strategy.

In an era of climate change, our profession must be prepared for all weathers and must plan accordingly. We must continually monitor the external environment and however cosy we might feel in our own cocooned environment, we must be mindful of the conditions outside.

Conclusion

We must consider a strategy that best serves the political, economic and healthcare climate of our times. We have important choices to make. Darwin or Dogma? Progression or regression? Survival or submission?

Events around the globe are conspiring to make this one of the most dynamic periods of chiropractic’s history. Great strides have been made. Regulation, education and research have flourished. Yet divisions persist. For chiropractic’s sake, let us meet our global challenges with fortitude, ensure sound professional governance and be ready to adapt as the healthcare climate changes.