A perspective on defining what chiropractic is....

I was recently privy to a fascinating discussion between a colleague I greatly respect and another chiropractor who is currently studying medicine.   A question was posed by the medical student, 

"Hello, I was wondering if I could ask a favour and ask for papers regarding the efficacy of chiropractic/HVLA on LBP. I've gathered a couple but would be nice to have a little more to share with medical students who largely have a negative attitude towards this profession."

The student later in the discussion talked about an incident where an orthopaedic surgeon presented to his class and on one of his slides there was a list of a half a dozen "alternative" modalities (including chiropractic).  The surgeon stated "They all don't work" in a definitive and authoritative manner.  When pressed by a student about what he thought about chiropractic and "manipulative" therapy, the surgeon responded that he didn't mind chiropractors and that they do some good, "After all, who wouldn't feel better after a back rub".  The chiro turned medical student was trying to pool resources to try and sway the others in his class to the efficacy of chiropractic care.

The reply from the chiropractor fascinated me.  He said that he believed that part of the problem is that the profession is too often defined by the "adjustment/manipulation".  

(I prefer the distinction between spinal adjustment and spinal manipulation to be made but others use them interchangeably so for the sake of the rest of this commentary, I will use adjustment. )

Then, when a patient case goes wrong, "chiropractic care/treatment" is called into question.  He deftly used the simile that this would be akin to defining medicine as "surgery" and therefore if a patient case goes wrong then medicine would be called into question.  But that's not what happens.  Because medicine isn't defined by any one therapeutic procedure or tool, its usually the individual clinician that is examined and its determined whether or not that procedure was an appropriate selection for that situation....or whether or not the procedure was performed competently.  Chiropractors don't get such luck.  We're all lumped together.

So we continue to battle this identity crisis.   Trying to define ourselves via the subluxation has been extraordinarily  difficult and now its seems that even though  the basis of our existence has been the success of the spinal adjustment (not the correction of the VSC), it too is proving to be an obstacle to our ascension to more respect by "mainstream" health care.  My colleagues argument that many professions "manipulate" is true and so I cannot begrudge his defining a profession as, 

"...a  body of knowledge, a skill base, a set of therapeutic tools, and a clinical framework for their intelligent and reasoned application."

Let's focus more on what we KNOW than what we DO because the emphasis on the adjustment is far too disproportionate in relation to the unique knowledge base and skill set we possess in the realm of spine and nervous system health.  The mantra of "Chiropractic doesn't work" is mistakenly defining us by our procedure.  So, now we fall into the trap of scrambling for research about that "procedure" to defend the stance that "Chiropractic works!".  We, essentially, play a hand in the creation and maintenance of this perception when we allow a misplaced focus on what we do.  Now it feels as though the validity of the entire chiropractic profession is on trial and that our existence depends upon this validation.

My colleague makes another very poignant point in how we can shift this focus by making some important distinctions in how we represent ourselves.  Chiropractic is not a "treatment".  Chiropractic is a profession.  The spinal adjustment is a treatment, or as I say, an application. So we don't DO chiropractic.  We ARE chiropractors.  As a profession, we are expert clinicians/diagnosticians in the domain of spinal health.  We possess a sophisticated base  of knowledge and manual skills that is specialized and unique in our approach to human health and illness.

So now we can reframe the discussion.  We can freely debate the effectiveness of spinal adjusting (or any other tool)in all sorts of situations, without needing to take a defensive position regarding the validity of the profession.  They are separate.  Like other health care professions, we are simply professionals engaged in intellectual inquiry regarding the mechanisms of our tools, no different from anyone else.

He makes another point, I did not consider.  With all this emphasis on the safety, cost and efficacy of spinal adjusting, have we ever considered shifting the focus to the cost and safety benefits of more effective diagnosis or assessment of spine pain (his example)?  Avoiding unnecessary and costly investigations with skillful clinical triage, knowing when other options can (and can't) be used and better managing the process to affect a better overall outcome.  This shifts the discussion to the value of what we KNOW and not just what we do. The public and the wider healthcare world, he argues, must value that first.  Then they will simply trust what we DO.  I completely agree.  

"The ones who know the most get trusted the most."

I have said this time and time again.  If we are going to present ourselves as spine and nervous system experts...then we must become masters at diagnosing and assessing these entities both in their world and in ours.

"Ultimately, the power and utility of any tool is proportional to the knowledge, expertise and reasoning ability underlying its use."