The John A. Sweaney Lecture: Berlin, Germany, March 2019, Given by Dr. Matthew Fisher: Becoming a Trusted Advisor in Health or Does Ego Get in the Way? An Australian Story

Abstract

The following is The John A. Sweaney Lecture delivered by Dr. Matthew Fisher at the biannual meeting of the World Federation of Chiropractic in Berlin, Germany, on March 19, 2019.

Introduction

It is with great sadness that I am presenting today so soon after the death of Dr John A. Sweaney. John was the first chief executive officer of the Australian Chiropractors Association (AusCA), guiding chiropractic in Australia through representations to government and other authorities (Fig 11, 2, 3, 4, 5). His interest in research and education were a constant throughout his time as a chiropractor and are clearly reflected in his legacy to the profession. He was a significant contributor to the profession; his graceful company, good humor, and fine intellect will be missed immensely. I offer my condolences to his wife, Inger, and sons, Rhys and Jens.

Fig 1.

John A. Sweaney, AM, DC, DSc (Hon), FICC, FACC, held the office of World Federation of Chiropractic (WFC) president from 1995 to 1998. The WFC was accepted into official relations with the World Health Organization during his leadership. Photo circa 1998. The John A. Sweaney Lecture is presented at the WFC biannual Congresses1, 2, 3, 4, 5 (photo reproduced with permission from Joseph C. Keating, Jr. archives).

Before he passed, John and I had discussed his first lecture on professionalism and the contribution of nonchiropractors.⁵ He was looking forward to attending the Berlin Congress as he had only missed 1 Congress since the first meeting in Toronto in 1989. As the current chief executive officer of the AusCA and a nonchiropractor, it is a privilege that I have been asked to present the seventh lecture given in his name.

I thank the World Federation of Chiropractic Council for inviting me to present Laurie Tassell, who eased me into the world of chiropractic, and Richard Brown, who has been a point of reflection for me. I acknowledge the current president of the AusCA, Anthony Coxon, and our immediate past president, Andrew Lawrence, as they have both surfed the journey we are on.

Presentation

It has not been an easy time in Australia. We recently attended a meeting of the Council of Australian Governments Health Council on March 8, 2019, where we heard community concerns about unsafe spinal manipulation on children performed by chiropractors and agreed that public protection was paramount in resolving these issues. Ministers welcomed the advice that the state of Victoria, Australia, has commissioned an independent review of the practice of spinal manipulation on children less than 12 years old (Appendix A), and the findings will be reported to the Council of Australian Governments Health Council, including any need for changes to the Health Practitioner Regulation National Law. Ministers will consider the outcomes of the independent review and determine whether any further changes are needed to protect the public. The AusCA is disappointed that the care we can provide children may be restricted even though the following can be said:

• 1.There is very little evidence of harm from spinal manipulation on children less than 12 years old.6, 7, 8, 9, 10, 11
• 2.There is evidence of the value parents experience of the informed care provided.12, 13, 14, 15, 16, 17
• 3.The extent of high-level evidence of chiropractic care for children is not extensive; however, the absence of evidence does not mean the absence of effectiveness.
• 4.If the law applied to all health providers is uniform and equitable, then many other professions should be restricted as they do have evidence of harm, yet the extent of high-level evidence for care is not extensive.
• 5.AusCA supports the minimization of harm, not the restriction of choice.

Subsequently, the Chiropractic Board of Australia has set an interim policy regarding spinal manipulation for infants and young children to protect the public until the outcomes of the expert review are known and a final policy is developed on the issue. The Chiropractic Board of Australia advises chiropractors to not use spinal manipulation to treat children under 2 years, pending the recommendations arising from the independent expert review.¹⁸

The AusCA is working to make appropriate representations and inform the community. The AusCA is pursuing several avenues, including legal advice on the uniform application of law and its impact on informed consumer choice. This outcome appears to be a reaction by the Minister for Health to media and advertising, not the care provided.

Strategic directions of the AusCA may have been subverted by the ego of a few chiropractors; however, I hope that the common good will be served by how the AusCA responds into the future in our trusted advisor quest.

So since I am an outsider to the chiropractic profession and was seeking a challenge, I came to the right profession for that outcome. Attending the World Federation of Chiropractic Congress in Athens and Washington, DC provided me with context about the chiropractic profession and where Australia sat. Having worked in public and private health care settings in Australia and lectured at universities and worked in leadership roles with other health professions, I continue to believe that there is a substantial opportunity and role for the chiropractic profession in health care. However, I believe that there are times when the profession gets in the way of its own achievements. Unless the profession can have respectful and reflective discussions with and about itself, I believe it will not realize its true potential. As John Kotter from Harvard Business School said, “an incredibly diverse team can work together and do astonishing things, and not just misunderstand each other and fight”¹⁹ and “Leaders establish the vision for the future and set the strategy for getting there.”²⁰

My questions include: What is the agreed vision for the chiropractic profession? Can this profession achieve astonishing things if it cannot agree to the vision and strategy or is it too busy having the fight through ego and past transgressions? Can the tribes within the profession and the community be brought along the journey if a common good is to be realized?

In Australia, the AusCA has chosen the direction of professionalism and supporting the responsibilities and obligations that are required of registered health care providers. This includes ethical commerce, given the profession exists in a private enterprise system where most of the funding is through out-of-pocket expense and private health insurance.

The chiropractic profession is full of diversity, passion, opinion, and satisfied patients, yet the noise in and around it is distracting. From my perspective, the discussion becomes polarized to an extent that people must choose sides and then simplistically consign people to one tribe or the other. Is a split necessary, and if so, would it be amicable? A division encourages a win–lose mentality, which is ultimately destructive. I believe the extreme ends of the political bodies make more noise than the silent middle majority who would rather get on with providing quality and evidence-informed care.

The AusCA has taken the view that, as a registered and regulated health care profession, the focal point should be a patient-centered, caring profession that delivers good health outcomes in a cost-effective manner. These are attributes sought by consumers and in Australia, much of how care is delivered is set by national law or standards.

The following are highlights of the issues that have been in play since 2015 when we commenced our messaging based on members being tertiary educated, low-risk, highly valued, regulated, patient-centered care providers.

• 1.Pointed criticism of the chiropractic profession has unfolded in the media due to the actions of a few individuals using social media. Some of the adverse media was generated by a few practitioners on one end of the philosophical spectrum with an anchored belief and wanting to win, yet seemingly at a high cost to the profession and its reputation. Yet other media was from organized antagonists of the profession who wanted chiropractic to be highly regulated or extinguished. This is what is playing out now and exemplifies an inequitable approach to regulation.

Headlines surrounding this issue have included:

• •“Melbourne chiropractor who cracked back of baby temporarily banned from treating children”²¹
• •“Chiropractor who claimed he could cure cancer convicted of false advertising”²²
• •“Chiropractors promoting antivaccination views despite rules”²³
• •“Chiropractor sparks outrage after being filmed hanging 2-week-old baby upside down and tapping his head as part of a controversial spinal treatment”²⁴

These headlines and events led to influential health bodies to call for restrictions to be implemented on practicing chiropractors. Yet, the good work being done by the rest of the profession was being left out of the headlines.

• 2.There is a focus on the regulation of advertising by health professionals and the propensity for some chiropractors to be out there and social media knowing no boundaries. The “crack” heard around the world was the headline, and a chiropractor was the first registered health professional in Australia found guilty of false and misleading advertising.
• 3.There is the question of the profession’s involvement in pediatric care, which includes questioning the appropriateness of care, the levels of evidence, and the facility where care is provided. In addition, the perceived position of the profession or actions of individuals on immunization was a driver of potential legislative change.

Since it began, this perfect storm has intensified. How the AusCA responds is being watched from many vantage points and perspectives. The reputation of the profession in Australia is again at risk and if it wants a viable future, then the AusCA is in the hot seat. It appears that some in the chiropractic profession want us to fail often from the winning and validation point of view. The opportunity to bury the hatchet was, in part, philosophically and personality driven. The frustrating part is the role that some in the profession have played in fueling this problem demonstrates their limited understanding of the obligation of health care providers.

Throughout these conversations and debates, I often hear chiropractors use the term cultural authority and who has it and who does not. It almost seems as if they believe that a scorched-earth policy within the profession would somehow achieve their attempt at authority. Instead, I suggest that maybe our conversations about achieving authority needs to evolve to one of building trust and becoming a trusted advisor not only to patients but also to those who influence the health care and practice environment. This was the direction that the Chiropractors’ Association of Australia (CAA), the precursor to the AusCA, had embarked on, yet much of 2015 and 2016 we were putting out fires while trying to develop the platform for our future.

In early 2016, the CAA released a Position Statement on Patient Care, Clinical and Professional Chiropractic Education²⁵ based on our understanding of key regulatory initiatives in Australia. The AusCA supports the Australian Charter of Healthcare Rights,²⁶ which describes the rights of patients and other people using the Australian health system. These rights are essential to make sure that, wherever and whenever care is provided, it is high quality and is safe.

The Australian Charter of Healthcare Rights recognizes that people receiving care and the providers of care have important parts to play in achieving health care rights. This helps everyone to work together toward a safe and high-quality health system. A genuine partnership among patients, consumers, and providers is important so that everyone achieves the best possible outcomes.

Further, the AusCA supports that patient-centered approaches to care can lead to improvements in safety, quality, and cost-effectiveness, as well as improvements in patient satisfaction. We support that chiropractors work in partnership with consumers.

In mid-2016, we released our Summary of Research Review,²⁷ as we recognized the need for ongoing robust, high-quality research focused on improving health outcomes through the delivery of evidence-informed diagnosis and management. Additionally, this document was designed to improve the research literacy of our members and their translation of evidence into practice.

Translational research has been identified as one such area by the National Health and Medical Research Council in Australia and is key to providing evidence-informed delivery of service.²⁸ Translational research primarily aims to improve the quality of patient diagnosis and disease management. It has relevance to identified areas of health burden that place a high cost upon the personal health, finances, and productivity of the Australian community. It also addresses areas where the profession is criticized. I believe that this is an area where the profession should focus.

Late in 2016, the Council of Australian Governments Health Ministers investigated unsafe practices of chiropractors and was exploring if the market was “failing” and therefore required further legislative intervention to minimize harm or potential harm. The CAA embarked on an advocacy path and released a Quality Care Statement to guide our advocacy efforts to circumvent proposed restrictions to practice.²⁹

This statement focused on 3 key areas: (1) the care of infants and children, (2) advertising, and (3) visiting health facilities to provide care where credentialing is required by law. Until recently, the environment had stabilized and to date, there has been no change made to national law, which we feel was a good outcome. However, this statement polarized segments of the profession who challenged the AusCA about what it stood for, yet the very outcome of our actions meant that the scope of practice was not restricted. Three years later, this issue has reemerged, this time with a greater threat, primarily as a result of self-promotion and a lack of regard for the regulatory environment.

Our efforts have provoked commentary from around the world; some of the comments are unsolicited and some ill-informed about context. The most recent media storm and direction from health ministers around the evidence for the involvement of the profession in pediatric care will no doubt lead to a test of potential market failure.

Approximately 300 > 000 Australians visit a chiropractor each week. In Australia, chiropractic ranks fourth behind dentistry, optometry, and physiotherapy in terms of health insurance utilization and economy. In 2017, the AusCA hired a market research agency to conduct a national consumer survey that provided further information for our strategy.³⁰ The report demonstrated that at a high level there are some negative perceptions of chiropractors. However, after people have visited a chiropractor, these views faded away. Additional facts from the survey showed that 7 in 10 people considered chiropractors to be professional, respectful, and knowledgeable. These are factors that are important for most people when choosing a health professional.

In the survey, medical general practitioners, dentists, and physiotherapists were more highly associated with all factors than chiropractors, and the uncertainty rate about chiropractors was 3 times greater than for the other professions. This changed once a person visited a chiropractor. Among this group of respondents, chiropractors were viewed similarly to how medical general practitioners, dentists, and physiotherapists were viewed among the general population. This suggests a gap in knowledge about the profession and raises the question of identity and what is understood about the profession.

According to the responses from this consumer survey, providing good value for money and portraying scientific rigor are areas that the chiropractic profession could improve on. These are factors that are important for people when choosing a health professional. Consumers who visited a chiropractor were also more likely to think chiropractors have a good or very good reputation and are more likely to recommend them to a friend or family member. This suggests that chiropractors improve perceptions of the profession when people visit them. However, the other side of this is that some chiropractors may start to believe their own press about efficacy and competency through the expressed satisfaction of patients, creating a conundrum. Does this contribute to the ego or the problem for the common good?

The survey also showed that Australian consumers who visited a chiropractor were more likely to agree that chiropractic therapies are effective in the treatment of spine and musculoskeletal conditions and that chiropractors offer a range of safe therapies for the treatment of infants. In summary, the key attributes that consumers are seeking from health care providers are knowledge, safety, effectiveness, trust, respect, and ethics.

So, how can chiropractic move forward to achieve trusted advisor status, particularly with the current storm? Firstly, the profession needs respectful conversations and a good understanding of the world we are in and the challenges that we face. These will guide our actions particularly if ethics and knowledge are core attributes.

Therefore, the issues we are addressing in Australia include (1) the role of the profession in health care; (2) the evidence base and its context in Health Practitioner Regulation National Law; (3) risk and unsafe practices; (4) advertising and Health Practitioner Regulation National Law; (5) bringing the membership, profession, and community along on the journey; and (6) reputation of the profession.

We need to understand what the community wants and expects from chiropractors. Can the profession address the difficult questions and behaviors that slow its progress? Can the solution be as simple as providing quality informed care at an appropriate cost that delivers an appropriate outcome?

I believe that most Australian chiropractors are concerned about the costs to the profession of individual actions and additionally the winning mentality at the polarized ends. In the meantime, the whole profession suffers. This compels the profession and the AusCA to make some critical decisions if the intent is, as our purpose states, that “to ensure that more Australians experience the benefit of chiropractic care.”³¹ This vision statement supports why we anchor on professionalism and would make an interesting change management project for any social scientist (see Appendix B for the Australian Chiropractors Association Strategic Plan 2018–2023).

From my perspective, it is disturbing to observe the lack of tolerance of different points of view with the chiropractic profession. Yet, we should be able to have a passionate exploration where the argument is attacked, not the person, and it avoids the imposition of views versus that of active listening.

The AusCA has given good deliberation to the question of where we would be if we took pathway X versus pathway Y, and we have tested this in various ways. We keep coming back to professionalism as the core attribute of the AusCA and that individuals can express their viewpoints and philosophy in keeping with professional expectation and obligation.

Adopting the approach of tolerance with boundaries does not imply a lack of commitment to one’s own beliefs; however, it provides for diversity. In many respects this epitomizes the Australian way as Australia is a vibrant, multicultural country. We are home to the world’s oldest continuous cultures, as well as Australians who identify with more than 270 ancestries. This rich cultural diversity is one of our greatest strengths and is central to our national identity. In the chiropractic profession sense, to be clear, we will not defend the indefensible and have drawn our boundaries.

A couple of quotes from John F. Kennedy come to mind here: firstly, “For time and the world do not stand still. Change is the law of life. And those who look only to the past, or the present, are certain to miss the future.”³² The journey of the AusCA through its commitment to professionalism and its investment in research demonstrates that we can adapt to change and don’t ignore facts, which means we have adjusted to the world we live in and in which the members practice. However, the paradox remains, “The problems of the world cannot possibly be solved by skeptics or cynics whose horizons are limited by the obvious realities” (Kennedy).³³ This is relevant for chiropractors where the bar of expectation is unequally applied across health professions.

At times the polar ends of the profession in Australia want a higher or lower bar than that required by the Health Practitioner Regulation National Law and that reasonably sought by the consumer. Leaving aside the emotions that often cloud reasoning, it is important to understand what the evidence is informing us of. The consumer expectation is of partnership, trust, care, and outcome.

During the journey of the CAA and AusCA over the past few years, a series of questions have been asked:

• 1.What are the basic ethical principles of the chiropractic profession?
• 2.What is the framework for the chiropractic profession to succeed?
• 3.How is the chiropractic profession accountable and how should it act?
• 4.What is the message the chiropractic profession wants to give and how does it want to be perceived?

We have articulated our desired outcomes through professionalism and ethics to be:

• •community benefit
• •increased utilization of chiropractic care
• •appropriate and ethical business growth
• •improved reputation of chiropractic care
• •improved understanding of the role chiropractic care plays within broader health care
• •growth of the AusCA brand among members, the public, and stakeholders

The AusCA surveys our membership to test many different perspectives, which then adds to the data we use to review our effectiveness. In 2017, we asked questions related to AusCA members’ views on practice and identity to inform our strategic directions. Some key relevance measures included that 97% of AusCA member respondents practiced in accordance with National laws; over 70% practiced using contemporary and evolving scientific evidence, and a collaborative, interprofessional approach; and approximately 30% used traditional theory and an independent/alternative health care setting approach. Regarding identity, approximately 65% use a multimodal approach to neuromuscular-skeletal care; 20% stated they were subluxation focused; and 15% had a wellness/preventative care approach.

Recently, we tested other domains with the AusCA membership based on our stated directions. Over 80% were satisfied with our stated direction and 88% with our broad approaches to communication; most other measures were 70% or above. Even with this information and using other sources including lived experience, some members of the Association and broader profession contest the findings given it may not fit their framework. This contested view impedes the outcomes the AusCA aims to achieve even though no one objects to the AusCA wanting to expand the market for chiropractic care. So, if the profession wants to increase its trust with the community, and therefore its role and value, can it be achieved when it struggles with its own identity? Can we simply break it down to the attributes of integrity, honesty, consistency, intent, and transparency?

The AusCA journey has commenced as part of the continuing story about and evolution of the chiropractic profession in Australia and what it contributes as a global citizen. It will be important that we have as many chiropractors as we can participating in the journey, and this can only be achieved with respect, learning, and tolerance at its core based on an understanding of obligation and national law. For a profession that is a low-harm modality of care for patients, it would benefit by learning how not to harm itself for it to truly realize its potential as a contributor and advisor in health care. If the profession is to forward its role in health care in Australia, the ego will need to be addressed for the common good to be served (Fig 2).

Fig 2.

Dr. Matthew Fisher is the chief executive officer of the Australian Chiropractors Association. He has extensive experience in the health sector through previous roles in the Australian Dental Association and both the public and private health care sectors in Australia. Matthew holds a Doctor of Philosophy and Doctor of Health Studies (honoris causa), as well as holding memberships with the Australian Institute of Company Directors, Australian Institute of Management, Australian Society for Association Executives, and Australian Chamber of Commerce & Industry. Matthew is an adjunct associate professor at Charles Sturt University and has attended Harvard Business School and London Business School.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this paper.

Contributorship Information

Concept development (provided idea for the research): M.F.

Design (planned the methods to generate the results): M.F.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): M.F.

Literature search (performed the literature search): M.F.

Writing (responsible for writing a substantive part of the manuscript): M.F.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): M.F.

Supplementary data

Appendix A

Independent review of the practice of spinal manipulation on children less than 12 years old.

Appendix B

Australian Chiropractors Association Strategic Plan 2018–2023.