The John A. Sweaney Lecture: Virtual, September 2021, Given by Dr Michele Maiers. A Time to Lead: Reflections During a Pandemic

Abstract

The following is The John A. Sweaney Lecture delivered by Dr Michele Maiers at the biannual Congress of the World Federation of Chiropractic that was held virtually on September 25, 2021.

Introduction

The John A. Sweaney Lecture was established in 2006 by the World Federation of Chiropractic (WFC) council to honor “WFC Past-President Dr John Sweaney of Australia by establishing a keynote address at all future biennial Assemblies of Members.”¹ One of the aims of the lecture is to “continue to challenge and inspire the chiropractic profession.”¹ Several lectures have been published since its inception.2, 3, 4, 5, 6 This article is an edited version of The John A. Sweaney Lecture delivered by Michele J. Maiers, DC, MPH, PhD, at the biannual Congress of the World Federation of Chiropractic held on September 25, 2021.

Presentation by Dr Michele J. Maiers

The phrase “May you live in interesting times” is used ironically to contrast relatively uneventful times, which might feel boring or mundane, with times of great excitement, which we know can be exciting for difficult or troubling reasons. Friends, we have been living in interesting times since we last convened for the World Federation of Chiropractic's Biennial Congress in 2019. Over much of the past year, I have spent considerable time reflecting on the concept of time. Like many of you, my busy life was filled to the brim with work, travel, family activities, and other commitments that came to a screeching halt in March of 2020. My days, which before never seemed to have enough hours in them, suddenly slowed. I felt as if time was standing still during some days. The busyness of life was on hold as we struggled to understand the threat of a new virus labeled SARS-CoV-2.^7,8

Almost overnight, neighbors closed their doors, city streets were quiet, and patient visits were canceled. I found myself in my kitchen wiping individual grapes my children were to eat with a disinfectant wipe. We were scared. Our knowledge paled in the uncertainty of the pandemic events. Perhaps most unsettling was not knowing how much time it would take to fully appreciate the scope of the threat of the COVID-19 virus: what it was, how to contain it, and how to manage the illness and death that it created in its wake.

As Pericles said, “Time is the wisest counselor of all.”⁹ Eighteen months have passed, and now is a good time to reflect on how we have fared. The results are decidedly mixed. As of today, the total number of global cases of COVID-19 has reached 213 million, and deaths are at 4.4 million; both statistics are likely underestimated.¹⁰ We do not know how many people are grappling with the effects of long COVID-19.¹¹ Social and economic inequities have been magnified.¹² Some of you may have temporarily closed your clinics, lost your job, or suffered professionally. Certainly, you suffered personally in some way. Many governments and public health agencies continue to wrestle with the balance of ethical health care policies and access, a global recession, and citizens whose collective consciousness has appeared at times to have been subjugated by our primitive lizard brains.

And yet, there have been brilliant moments of hope that remind us of what we are capable of. We slowed down. We checked in on each another. Neighbors supported neighbors. The garbage collector and the shelf-stocker at the local grocery store became local heroes. Families who could spent more time with each another. My family contributed to sales of board games and jigsaw puzzles, which soared during lockdown.¹³ Importantly, we had time to just be.

There has been renewed interest in lifestyle medicine and preventive health measures to reverse the trends of obesity and chronic disease that made some individuals more susceptible to serious COVID-19 illness.14, 15, 16 International scientific collaboration and innovative technology fast-tracked the development of COVID-19 vaccines at a rate that could not have been imagined just a few years ago.¹⁷ To date, a quarter of the world's population has been fully vaccinated against COVID-19.¹⁸ Applications to public health schools have jumped 23%.¹⁹

During this time, we have taken stock of our careers and priorities and reevaluated what really mattered to us. We have thought about how we use this time as a moment of inflection to make changes that we might have otherwise been less inclined toward. It is in this spirit that I frame the 2021 World Federation of Chiropractic Sweaney lecture.

Now Is the Time

Friends and colleagues, now is the time. Now is the time to ask more of ourselves. Now is the time to truly understand our communities’ needs. Now is the time to partner with a broader range of stakeholders. Now is the time to actualize the untapped potential of the chiropractic profession.

I often reflect on a presentation that Scott Haldeman delivered in 2015.²⁰ Dr Haldeman was the first to deliver the American Chiropractic Association's McAndrews Leadership Lecture.²¹ The lecture series honors the legacy of Jerome McAndrews, doctor of chiropractic and well-known leader within the chiropractic profession in the United States. His brother was George McAndrews, the lead legal counsel representing Chester Wilk and other chiropractors who sued the American Medical Association for restraint of trade and won.22, 23, 24, 25, 26, 27, 28, 29

Dr Haldeman provided a first-hand account of how much the chiropractic profession had changed and how perceptions of us had changed over the preceding 50 years. He highlighted the opportunities available to the chiropractic profession moving forward if we conduct ourselves in a manner that is evidence-based, patient-centered, and collaborative in nature. Finally, he left the American Chiropractic Association with a challenge. Dr Haldeman noted that the profession's challenges of the present were not the challenges of the past. The chiropractic profession was in a unique moment of time where we needed to fully engage as participants in the evolution of health care delivery. This necessitates us being part of policy discussions, assuming leadership roles, prioritizing the needs of the public over that of the profession, and staking our claim in spine care. The window of opportunity, he warned, was closing due to competition from other professions who were motivated to move into the spine care space. He estimated that the chiropractic profession had 5 years to establish cultural authority in these areas before the opportunity was lost. He stated that it was the time to act.²⁰

During Vivian Kil's 2016 Sweaney lecture, she noted Dr Haldeman's challenge.⁴ Both she and I identified this challenge as the focus of our presentations. Her presentation was 5 years ago, which is the same time that Dr Haldeman challenged the chiropractic profession to act. Now seems an appropriate time to ask ourselves, have we risen to meet Dr Haldeman's challenge? In some impressive ways, I feel that we have.

Meeting the Challenge

In 2018, a series of papers were published on the prevention and treatment of low back pain.30, 31, 32 This was a landmark moment for the chiropractic profession for several reasons. These papers shone a spotlight on the burden of back pain.³⁰ The Global Burden of Disease report demonstrated that back and neck pain were leading causes of years lived with disability around the world.³³ While chiropractors treat a range of conditions, back and neck pain as a leading public health problem resides squarely in our wheelhouse. A recent systematic review showed the most reported reason people seek chiropractic care is back pain (49.7%), followed by neck pain (22.5%), and extremity complaints (10%).³⁴ Some chiropractic associations have coalesced around primary spine care in response to this significant need.³⁵

The Lancet series was important for not only elevating the discourse around the burden of spine pain but for calling to task providers and health care systems who overutilized low-value services. This included the liberal use of imaging, opioids, spinal injections, and surgery.³² As an alternative, the series championed high-value, evidence-based services when care was needed, including exercise, advice, and spinal manipulation.³² Unsurprising to the chiropractic profession, these recommended interventions constitute the majority of therapies delivered in chiropractic practices.³⁶

The Lancet recommendations mirror those issued by the American College of Physicians in 2017, whose guidelines for back pain favored the treatments more commonly associated with the care delivered by chiropractors than standard medical care.³⁷ These guidelines advocated non-pharmacological interventions first for spinal conditions and created an opportunity for chiropractors to play a greater role within the larger health care system as deliverers of high-value spine care.

As a profession, we should be proud of the quality and caliber of research conducted in our field over the past several years. Research opens doors. The language of science is necessary to gain a seat for the chiropractic profession around tables of influence. The papers published in the Lancet were an example of chiropractors publishing as experts in spine care, with experience and research expertise to contribute to the international conversation on back pain. Other examples of scientific communications include research published to inform the Global Spine Care Initiative,38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 use of chiropractic among older adults,^51,52 and nonpharmacological pain management.^53,54

In 2018, the Global Rehabilitation Alliance⁵⁵ was founded to advocate for quality, coordinated, and affordable rehabilitation to meet population needs. Optimizing function and improving quality of life through rehabilitation is central to many chiropractic practices.^36,47,56 Rehabilitation contributes to the World Health Organization's Sustainable Development Goal 3, which is to ensure healthy lives and promote well-being for all at all ages.⁵⁷ The WFC is a founding member of this organization and supports the Sustainable Development Goals 2030. As well, World Spine Care⁵⁸ continues to expand in its mission to improve lives in underserved communities through sustainable, integrated, evidence-based spine care. Chiropractors remain intimately involved at all levels of this organization, its mission our entire profession can rally around.

During the past 5 years, chiropractors have served in some of the highest levels within notable health care policy, advocacy, and research organizations, including leadership within the Global Alliance for Musculoskeletal Health, contributors to the World Health Organization's guidelines for the management of low back pain, and the chair of the Patient-Centered Outcomes Research Institute in the United States (US). Increasingly, chiropractors are invited to participate in high-level discussions to share their expertise with a range of health care stakeholders, with a common goal to improve the health and wellbeing of the communities they serve.

Over the past 5 years, chiropractic clinical care services have expanded in military and veterans’ systems.59, 60, 61 The benefits of chiropractic care have been on display worldwide, helping athletes perform at peak levels in the Olympics and in professional sports.⁶² The number of accredited chiropractic programs continues to grow, as does the number of countries where chiropractic is legally recognized.⁶³

During the pandemic, there were examples from around the world of chiropractors stepping up and stepping in to fill needs within our public health infrastructure.64, 65, 66, 67 Chiropractic physicians in the US acted as essential health care providers, maintaining safe and open practices to keep front-line workers on the job, supply chains moving, musculoskeletal cases out of urgent care facilities, and chronic pain sufferers off opioids and other narcotic medications.^65,66,68 The Chiropractic Doctors Association of Hong Kong provided weekly radio and newspaper announcements to share up-to-date information about COVID-19 with the public. The Puerto Rican Chiropractic Association teamed up with a multidisciplinary group of providers to address health care needs after a series of devastating earthquakes and was recognized to provide emergency musculoskeletal care during the pandemic. The past president of the WFC sanitized ambulances in the Netherlands. A family of chiropractors in the US became the COVID-19 emergency management health care directors in their region, setting up community testing centers and coordinating with local hospitals and the heads of infectious disease control. Chiropractors around the world pivoted to telehealth. Chiropractic professional organizations secured personal protective equipment, worked to combat false information, and supported members who, in turn, supported their patients. There were scores of chiropractors who continued to quietly provide high-value care to patients in their communities.⁶⁶ These services helped by alleviating pain and suffering, supporting healthy aging across the lifespan, and elevating the conversation away from disease management toward health creation.

It can be tempting to focus on negative news, our collective frustrations, and all that we have not yet achieved as a profession. Advancement and recognition of the chiropractic profession remain uneven around the globe. In our polarized society, it can be difficult to understand the actions of some of our colleagues, and it is too easy to get drawn into arguments on social media.

Despite these challenges and before the pandemic becomes the backdrop of “remember when” stories, we should take advantage of this disruption to reevaluate our standing as a profession. We must purposefully rededicate ourselves to a global vision of who we are—an evidence-based, people-centered, interprofessional, and collaborative chiropractic profession.

Chiropractors in the US are recognized as essential health care providers.⁶⁴ While this designation was important to keeping practices operating during pandemic restrictions, now is the time to ask, how well are we meeting society's expectations of essential health care providers? How are we ensuring all communities have equitable access to chiropractic care? Do we deliver services that reflect the full complement of our education? Do we regularly take our patients’ blood pressure? Do we counsel patients about nutrition, physical activity, sleep, and stress? Are we appropriately coordinating care with other health care providers and connecting our patients with social services when needed? We are well known for managing musculoskeletal conditions, and patient satisfaction with chiropractic care is incredibly high.69, 70, 71, 72 But are we doing as much as we can within our scope of practice and educational attainment to live up to the designation of “essential” health care providers? For many of us, the answer is yes. But for all of us, the answer may be that we could probably do more. Now is the time to take a fresh look at our communities’ needs and ask ourselves what more can we do as a group of health care providers to provide essential health care.

Whether we are viewing the health needs of our communities from a developing nation or from a region that enjoys a disproportionate share of the world's wealth, we must consider that we as a profession may not have done enough to help address disparities in the social determinants of health, including racism, sexism, ageism, and the uneven distribution of resources. Chiropractors are privileged leaders in our communities, and each of us has a role in creating awareness and working toward solutions to fundamental injustices. Doing so requires that we listen deeply to understand the needs of others. We must think creatively about how we as chiropractors can best meet society's needs, as part of a team, and with answers that may not always be solely “the chiropractic adjustment.”

The needs of our communities are always changing. Now is a good time for us to ask, are our educational institutions training the next generation of chiropractors to meet society's needs of tomorrow? Do our graduates have both the technical and interpersonal skills needed to work in integrative settings and contribute to patient-centric models of care delivery? Do we regularly engage in continuing education and use practice resources to leverage research and improve clinical outcomes? Do we give graduates the skills needed to discern credible information from deceptive propaganda? Can we accurately synthesize the staggering amount of information that comes into our newsfeeds, email inboxes, and earbuds every day? Are we arming ourselves and our colleagues with skills of self-care and resilience to prevent burnout? Now is the time for us to leverage interprofessional and electronic resources to optimize our potential to be leaders in the health care system. Our path forward must be grounded in equal parts critical thinking and compassion.

We find ourselves at the nexus of staggering public health problems. Economic inequities and racism have made health disparities during the pandemic even more acute.⁷³ The pandemic has also amplified the magnitude of mental health problems,⁷⁴ which some have difficulty acknowledging. In Europe and North America, our population is aging at a rate that leaves us unprepared economically and in health and social infrastructure. In countries like the US, we are seeing opioid-related deaths rise once again.⁷⁵ And, lest we forget, back pain remains a leading cause of disability.⁴⁰

Chiropractors are outside-of-the-box thinkers from an outside-of-the-box profession with an incredible value proposition. The care that we provide is safe, effective, and cost-efficient relative to the prevailing methods of managing spine-related problems.^37,76 Patient satisfaction with chiropractic care exceeds that of other health care providers.^77,78 We spend time and connect with our patients on a level that my medical colleagues have told me they are envious. These qualities give us the opportunity to develop trust with marginalized communities, become a touchpoint for mental health intervention, and address the full breadth of variables that contribute to health and wellbeing. We provide a biomechanical solution to functional problems and the relationships necessary to support the psychosocial needs of our patients. The quality of chiropractic education continues to improve, and chiropractors increasingly work within integrative, multidisciplinary environments.³⁶ What could possibly be holding us back?

As with most things, the answer is us. Historically, our allegiance to the past has sometimes clouded our view of the future. But as the saying goes, the past is made to learn from, not to live in. The chiropractic profession has matured considerably over the past several decades. While most of us honor the past, our current focus is on being better practitioners and contributors to the health care system today and into the future.

I became the president of the American Chiropractic Association in 2021, and the pandemic has been an interesting time to assume this role of a national organization. While leading during such an unsettled time, my greatest lesson so far has been the value and importance of grace. If ever there was a time to set aside our judgment of others and align ourselves around our commonality and showcase all that is good in our profession, that time is now. Let us choose to align around high standards of ethics and the unifying factors within the chiropractic profession. I feel that which side of the philosophical spectrum that someone is on has always been the wrong question to ask. That tired discussion is a profession-centric and false dichotomy that we need to leave behind us. After all, what you resist, persists, and the opportunity costs of that distraction have been considerable.

Being EPIC

It is time for us to truly align around the highest standards of health care and ethics. We live these standards by being evidence-based, people-centered, interprofessional, and collaborative (EPIC). The WFC's clarion call to be EPIC is the right message at the right time.⁷⁹ Figure 1 shows the WFC #BeEPIC campaign.⁷⁹

Fig 1.

World Federation of Chiropractic #BeEPIC campaign. Reprinted with permission from the World Federation of Chiropractic.⁷⁹

An evidence-based practice is the bedrock of an ethical practice. The quote “Do the best you can, until you know better. Then, when you know better, do better” has been attributed to Maya Angelou.⁸⁰ To me, this embodies what evidence-based practice is all about. We rely on our clinical expertise and the expertise of our mentors and teachers to guide us in good clinical decision-making. We use our clinical expertise to do our best. High-quality research evidence provides us with invaluable knowledge to know better. We are ethically obligated to strive to know better so that we can do better. A commitment to being people-centered amplifies our dedication to patient-centeredness and focuses on what we can do to support social, political, and structural changes to enhance the health of our communities. Our participation in advocacy, our commitment to diversity, equity, and inclusion, and our responsibility to deliver culturally relevant care are critically important areas of concentration for chiropractic. We must go beyond discussing these critical issues; instead, we need to create actionable plans to become a more people-centered profession in the decade ahead.

Those involved with interprofessional care recognize not only that chiropractic can contribute to multidisciplinary health care teams but also the value of what other disciplines and ancillary fields can contribute to comprehensive health care. Whether that means comanaging a case with our local medical orthopedist or connecting a patient in need with a local food charity, successful interprofessional care places the person at the center of a team. Members of the team commit not to the tribe they identify with but to contributing their skills and talents in a way that elevates everyone, most notably the patient. None of this can be accomplished without a spirit of collaboration. This requires humility, courage, deep listening, clarity of mission, and other soft skills that are the most important skills for success in life.

Evidence-based, people-centered, interprofessional, and collaborative—who would not want to be EPIC? And the most exciting part is that we have what we need to be truly EPIC. Chiropractic has the value proposition, the tenacity and the grit, the heart and the soul that are needed to accomplish amazing things. This is why, in spite of a history of marginalization and subversion,³⁶ we persist and, in many ways, flourish. The time to be EPIC is now, and the decision to be EPIC is ours.

I want to wish not that we live in interesting times but that we learn from interesting times (Fig 2). My wish is that we seize this moment to actualize our full potential—as chiropractors, as healers, as leaders, and as good citizens in the world. Now is the time to ask more of ourselves as each of us steps up within our own spheres of influence to better meet the needs of the communities we serve.

Fig 2.

Michele J. Maiers, DC, MPH, PhD, is the Executive Director of Research and Innovation at Northwestern Health Sciences University and is the president of the American Chiropractic Association.