- Email: [email protected]
1C.4. What will it take to gain acceptance?
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33. Luijsterburg PA, Verhagen AP, Ostelo RW, van den Hoogen HJ, Peul WC, Avezaat CJ, et al. Physical therapy plus general practitioners’ care versus general practitioners’ care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Eur Spine J 2008;17(4):509—17. 34. Carr JL, Klaber-Moffett JA, Howarth E, Richmond SJ, Torgerson DJ, Jackson DA, et al. A randomised trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area. Disabil Rehabil 2005;27:929—37. 35. Critchley DJ, Ratcliffe J, Noonan S, Jones RH, Hurley MV. Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation. Spine 2007;32(14):1474—81. 36. Foster NE, Dziedzic KS, van der Windt DAWN, Fritz JM, Hay EM. Research priorities for non-pharmacological therapies for common musculoskeletal problems: nationally and internationally agreed recommendations. BMC Musculoskeletal Disorders 2009;10:3. 37. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ 2000;321:694—6. 38. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health. BMJ 2007;334:455—9.
doi: 10.1016/j.clch.2010.02.017
1C.4. What will it take to gain acceptance? David Byfield BSc Hons, DC, MPhil, FBCA, FFEAC, FCC Head of Division Chiropractic, Head of the Welsh Institute of Chiropractic, Department of Professional Education and Service Delivery, Faculty of Health, Sport and Science, University of Glamorgan, Wales, UK
Introduction It has been stated that chiropractic is a large and well established healthcare profession, particularly in the United States, where it has made substantial gains in terms of educational standards, credible research contribution, legislation and market share.1 The profession has also made considerable progress in other jurisdictions, most notably the UK and parts of Europe in terms of statutory regulation, university based education and postgraduate development. Nevertheless, the profession is facing a number of professional issues that may threaten its future progression despite these local achievements; moreover, the situation is not being ameliorated by the fact that the profession is still viewed by many as somewhere between mainstream establishment and complementary and/or alternative (CAM) practice, a sort of ‘‘no man’s land’’, despite achieving many mainstream characteristics such as statutory legislation and publicly funded educational programmes. As a result, conflicting views have arisen between the public, the healthcare community and the chiropractic profession, which may have contributed to this current lack of identity and confused image.2 To be honest, the chiropractic profession doesn’t do itself any favours, particularly when it chooses to disregard the impact associated with perpetuating outdated principles conceived in the 19th century, and the influence this has on its current professional standing. Embracing modern health science would be one crucial way forward to shift public opinion and our status in the health care community. At the time, Haldeman, Meeker and Mootz1 proclaimed that the next decade will determine whether or not the chiropractic profession will be granted mainstream status and fully integrated into all healthcare systems or, to the contrary, continue to be labeled as a CAM profession with the inherent stigma and prolonged skepticism attached to this label and those who practise under this banner. Since 2002, the chiropractic profession has accomplished a great deal, but is a long way away from realising full integration in national healthcare systems and accepting responsibility associated with mainstream status. There are many reasons for this current state of affairs.
Reflection Recently, Murphy et al. (2008)3 have maintained that, despite its longevity, the chiropractic profession has not achieved its full potential and has failed to demonstrate the evidence required for future sustainability within the healthcare environment. Their analysis is focused on issues within the United States, but some of their concerns transcend boundaries and may threaten future professional advancement along with respect and credibility within the healthcare community and society generally. The numbers speak for themselves and according to Lawrence and Meeker (2007),4 chiropractic utilization (market share), for low back pain in
Lectures
103
the US varies from 6% to 12% of the population. More alarmingly, Tindle et al. (2005),5 report that the percentage of the population in the US utilizing chiropractic care has actually diminished from 10% between 1992 and 1997 to 7.5% from 1997 to 2002, which in some way may indicate chiropractic’s diminishing position in the healthcare league table and a trend towards a dwindling share of the market. This may be a cyclical pattern at the expense of the ascendency of more ‘‘popular’’ interventions but, at the end of the day and all things considered, there are clear signs that the profession may be facing a downward spiral and a crisis situation that requires immediate attention.3 The question then arises, ‘‘Can the chiropractic profession overcome its problematic past to become an established and respectable mainstream profession within the foreseeable future?’’ This is a very complex question and it has been suggested that, in order for the profession to turn this around, succeed and overcome an unstable market share, poor social image, lack of public confidence and low status among other health professions, it must consider making appropriate and immediate changes as part of a clear forward thinking strategy similar to those adopted by the podiatric profession in the United States.3,6 The profession urgently needs to create a vision for itself and establish a cultural authority as non-surgical, musculoskeletal spine specialists, providing a model of care that is supported by a substantial evidence base, coherent with and benchmarked against national health system governance and clinical care pathways. The chiropractic profession, if it wishes to be a part of mainstream health care, cannot be all things to all people and promulgate outdated and untested clinical principles and expect to be taken seriously by an informed society. It must make critical choices and unified decisions about its identity and where it wants to fit into the milieu of health care. This may necessitate narrowing the system(s) we treat and expanding our therapeutic scope, thereby forcing us to reflect on and accept the limits of our professional influence to secure a future. This view does not reduce, nor should it impact on, our aspirations regarding our primary contact role, but the chiropractic profession has to demonstrate that it has the capability of re-defining itself as a responsible and modern profession underpinned by contemporary healthcare values and science. Murphy et al. (2008)3 have identified a number of key areas for consideration as part of a strategy to focus on the future of the profession, including:
Public health participation Educational standards & expansion Identity/cultural authority Professionalism & ethical behavior Social responsibility.
These authors have also reflected upon the development of the podiatry profession in the United States and their successful integration and wide utilization within the healthcare system.3 The podiatry profession as a whole has been very successful in these areas, whereas the chiropractic profession has simply not even come close, due to its lack of unity and unwillingness to establish a suitable science based identity. Unification of the profession is as remote today as it has ever been and is, in some ways, responsible for the lack of progress Chiropractors are situated in the healthcare community at a primary contact level, providing care for their patients and, as a result of this favourable position, they should actively embrace important public healthcare initiatives instead of denouncing extremely successful public health measures such as vaccination. It would be a different scenario if chiropractors were qualified immunologists with years of research and practice experience in these matters; however, employing theories that are, at best, outdated and weak to substantiate these claims is no longer tenable and only adds to the professional embarrassment that we face, along with continued isolation and uncertainty. Participating in public health schemes and health promotion will enable chiropractors to work alongside other health professionals and agencies, giving chiropractors an opportunity to provide their patients with information and strategies to deal with longstanding issues such as tobacco use, obesity, poor diet and physical inactivity and the consequences these have on overall health. Educational curricula need to be flexible and designed to accommodate these competencies.
Solution/strategy It could be argued that prolonged isolation and impaired integration are the greatest obstacles for the profession to overcome for its future growth within healthcare delivery. The profession works in relative isolation and has yet to create a clear model for its services. Integration would come at a cost, but this would be a huge investment in future advancement. No doubt there will be many who may object that the profession will
104
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lose its identity and be forever subsumed by the medical establishment. It is my view, that this is simply paranoia and myth. There are numerous examples throughout the international community where chiropractic has integrated effectively. Denmark and Switzerland are two very good examples of professional integration in both education and national health infrastructure; nevertheless, there needs to be more expansion and sustained development in these areas. This was featured at the recent World Federation of Chiropractic (WFC) Biennial Conference in Montreal, Canada (2009), where a few very high calibre projects were highlighted including: Chiropractic student rotations in veterans’ medical centre/hospitals in the US as part of their undergraduate education Government policy changes in Ontario, Canada requiring all health sciences students to have formal interprofessional education to better understand all healthcare professionals and encourage collaboration The Harvard Medical School project, integrating various complementary services, including chiropractic, and resulting in greatly improved patient outcomes Details of the full integration of chiropractic services within the core sports medicine team for the Vancouver Winter Olympic Games in 2010.7 This conference also brought together eight chiropractic Research Chairs at leading Canadian Universities, who are conducting their own research and supervising other chiropractors pursuing PhDs, illustrating what can be achieved when individuals are committed and supported financially to realize their aspirations. The Chiropractic Research Unit at the University of Glamorgan was included in the UK National Research Assessment Exercise (RAE) in 2008, and its work successfully judged against national standards with other university research units. More importantly, chiropractic undergraduate education must become integrated within the higher educational infrastructure at university level, which brings access to public funds, research opportunities and staff development. The chiropractic schools in the US have failed to achieve this objective8; however, there are increasing numbers of university based programmes in, for example, the UK, Denmark, Spain, Switzerland, Mexico, Brazil, Malaysia and Australia. Despite the shortcomings of residing in a large public institution, the overall benefits of moving away from private educational institutions are far more important. Currently, there are 39 chiropractic educational institutions worldwide, which possess both international and, in many instances, national accreditation by a competent authority. Of these institutions, 16 are placed within a university and, with one exception, all of these are outside the United States. In my opinion, public funding will have a significant impact on chiropractic education, and will no doubt ensure a solid future for increasing student recruitment. In addition, there are a number of other benefits associated with the state university system including access to specialist lecturers, subject expertise, expanded library access, sport facilities, housing and other potential contacts related to the national healthcare system that will benefit chiropractic students and their educational development. The profession must move in this direction to enable student access to high quality education and minimise the excessive financial burden, which may influence individual practice style and ethical behaviour following graduation. Chiropractic students should be supported in as many ways as possible to achieve their professional goals and future career. A recent study of US chiropractic institutional curricula revealed programmes which, on average, consisted of 4820 h of both classroom and clinic training, which exhibits considerable commonality between chiropractic and medical education.9 The greatest identified difference between medical and chiropractic educational programmes appeared to be in the extent and diversity of the clinical training.9 Medical education included more than twice as many hours in clinical training than chiropractors in the US1 and, in my opinion, this remains a significant flaw in our educational programmes and a need for future development as the profession strives towards a more integrated role in educational delivery. An integrated model exists at the University of Southern Denmark and at the University of Glamorgan; we have pioneered a pilot student placement programme in two local hospital trusts near the university, as a direct result of perseverance as well as our contacts in our Faculty of Health, Sport and Science. There are plans to roll the programme out fully and expand the scheme within the curriculum. Modern health care delivery is integrated, patient focused and multidisciplinary in nature; therefore, it is imperative that chiropractic undergraduate education expands and develops sustainable inter-professional links within the wider healthcare community to prepare graduates for this integrated care delivery model. The purpose of such collaborations would be to broaden student experience, enrich the undergraduate programme and interact directly with mainstream healthcare professionals as part of the healthcare team.
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This development will require graduates to demonstrate proficiency in a new knowledge base and clinical and communication skills. There is no doubt this will pose a significant challenge for most chiropractic undergraduate institutions, as there are very few models where the infrastructure and links are sufficiently well developed to be fully integrated with other health professional or medical training. Curricula would require re-organisation and planning to accommodate this element of training. Historically, chiropractic education has developed in isolation from the rest of the healthcare delivery system. As a consequence, any collaborative relationships tended to be developed locally and poorly coordinated. It is my opinion that, in order to cultivate this type of inter-professional education, the chiropractic profession must establish and adopt a modern professional identity that is reflected in the educational outcome. Secondly, the profession must determine its role and identity in the healthcare delivery system compatible with current health care evidence based philosophy. Such models currently exist in Europe, South Africa and Australia and have eclipsed the private institutional model in North America. The financial burdens associated with private education are prohibitive for prospective students and their families; for sustainable growth and credibility, a university based model must develop internationally for any opportunity to develop these important collaborative links. Collaborative networking and expansion of the undergraduate experience is an educational challenge for chiropractic educators. Efforts must focus on purpose and appropriate learning outcomes. The healthcare environment has changed dramatically and our undergraduate programmes must reflect contemporary, inter-disciplinary approach to patient care. Masters level education is now the model of choice for undergraduate education, whether it is the Bologna ‘‘3 + 2’’ model or the integrated masters programme. The key to the integrated masters is the ‘‘masterliness’’ element, which raises the level of learning, particularly during the clinical training aspect of the degree. At this point, students must be selfdirected, innovative and original in being able to tackle complex clinical problems and make appropriate decisions regarding patient management. In order to achieve this, and even though students are under supervision during this process, they must exhibit specialised knowledge, ethical behaviour, complex problem solving and effective communication which constitute activities consistent with in clinical practice. It is this level of ‘‘supervised experience’’ that gives this the ‘‘masters’’ element. Students also participate in an original research project as part of the ‘‘masters’’ process to develop independent inquiry, which is a mandatory component of the degree. This process encourages a research and scholarly active culture within the programme and drives staff and curriculum development. The profession must also establish its cultural authority in order to create a useful role and identity and purpose within national healthcare systems and not be regarded as an alternative competing profession. The chiropractic profession needs to build on its obvious strengths and address its weaknesses in order to sustain a level of success. For example, the Spine Care Model as described by Nelson et al. (2005)6 suggests that chiropractic should be a neuromusculoskeletal specialty, with particular emphasis on the spine and consists of the following elements:
Chiropractic as a portal of entry (POE) — physician/provider. Chiropractic as a willing and contributing part of the evidence based healthcare (EBHC) movement. Chiropractic as conservative/minimalist healthcare provider. Chiropractic as a fully integrated part of the healthcare system, rather than as an alternative and competing healthcare system.
Nelson and his co-authors presented a cogent debate regarding the role and identify of the chiropractic profession, which could essentially be classed as a landmark paper as it describes a contemporary model of how the chiropractic profession should develop its own cultural authority within mainstream health care in the future. It is clear, coherent and professionally defensible. The profession needs to define for itself what its parameters are and how to validate these, despite the mitigating forces both within and external to the profession that will impede such progression. Nelson et al. (2005)6 proclaimed that the chiropractic professional identity should be based on spinal care as the defining clinical purpose and chiropractic should be integrated into healthcare provision locally with implementation of accepted high standards of professional ethics. They addressed a number of issues and presented clear and concise statements for adopting this model. They unmistakably stated that, ‘‘Cultural authority is granted by society based on recognition of a professional group’s competency and legitimacy with respect to the domain over which it professes dominance. With cultural authority comes a certain degree of autonomy and privilege.’’ This is profound,
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particularly with respect to professional credibility, and the easiest way to diminish trust and the level of cultural authority is to continue to embrace unethical professional activities. Cultural authority means that one has the right to define truth. Thus, if we can define for the public that chiropractic care is a safe and effective intervention and they accept this fact, then the profession can proclaim cultural authority. This is the heart of professional credibility because one could ask the question, as Nelson et al. (2005)6 have plainly stated, ‘‘Why is modern evidence largely being ignored by policy makers and the access to chiropractic care being impeded by arbitrary obstacles?’’ The proposed model will assist the profession in integrating into mainstream health care whilst maintaining its own identity. This is an important consideration at this point and it strongly recommended that all chiropractors read and digest this publication if we are to move forward. What better place to be than to serve the public as a unified profession providing integrated conservative interventions as spinal healthcare specialists supplying services that society want and need.7
Conclusion There is no questioning the fact that the chiropractic profession has made substantial progress in educational development, research and professional practice on a global basis but the achievements are not uniform across all jurisdictions. Further progress, particularly integration into healthcare systems as a credible, respected and widely utilized profession, will require a concerted and unified effort based upon an agreed strategy employing the example set by the podiatry profession in the US as a useful guideline. There is an enormous opportunity for the profession to become valued, non-surgical spinal care specialists offering expertise in diagnosis, treatment and patient management in order to gain any sense of acceptance within the wider healthcare community. This would have to be a long term strategy and the profession would have to be united in this endeavor. The future has to be led by the sensible majority, who want to integrate their services to best serve their patients and the public to secure a prosperous future. This presentation outlines the problems facing the profession; discusses achievements to date and frames a strategy to methodically work towards achieving these aspirations and goals.
References 1. Haldeman S, Meeker WC, Mootz RD. Back to basics...The state of chiropractic research. Top Clin Chiropr 2002;9(March (1)):1—13. 2. Meeker WC. Public demand and the integration of complementary and alternative medicine in the US health care system. J Manipulative Physiol Therap 2000;23:123—6. 3. Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? Chiropractic Osteopathy 2008;16:10. 4. Lawrence DJ, Meeker WC. Chiropractic and CAM utilization: a descriptive review. Chiropractic Osteopathy 2007;15:2. 5. Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medicine by US adults: 1997—2002. Altern Ther Health Med 2005;11(January—February (1)):42—9. 6. Nelson DF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, et al. Chiropractic as spine care: a model for the profession. Chiropractic Osteopathy 2005;13:9. 7. Chapman-Smith D. The Road to Integration. The Chiropractic Report 2009;23. 8. Wyatt LH, Perle SM, Murphy DR, Hyde TE. The necessary future of chiropractic education: a North American perspective. Chiropractic Osteopathy 2005;13:10. 9. Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education. Altern Therap Health Med 1998;4:64—75.
doi: 10.1016/j.clch.2010.02.018
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33. Luijsterburg PA, Verhagen AP, Ostelo RW, van den Hoogen HJ, Peul WC, Avezaat CJ, et al. Physical therapy plus general practitioners’ care versus general practitioners’ care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Eur Spine J 2008;17(4):509—17. 34. Carr JL, Klaber-Moffett JA, Howarth E, Richmond SJ, Torgerson DJ, Jackson DA, et al. A randomised trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area. Disabil Rehabil 2005;27:929—37. 35. Critchley DJ, Ratcliffe J, Noonan S, Jones RH, Hurley MV. Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation. Spine 2007;32(14):1474—81. 36. Foster NE, Dziedzic KS, van der Windt DAWN, Fritz JM, Hay EM. Research priorities for non-pharmacological therapies for common musculoskeletal problems: nationally and internationally agreed recommendations. BMC Musculoskeletal Disorders 2009;10:3. 37. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ 2000;321:694—6. 38. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health. BMJ 2007;334:455—9.
doi: 10.1016/j.clch.2010.02.017
1C.4. What will it take to gain acceptance? David Byfield BSc Hons, DC, MPhil, FBCA, FFEAC, FCC Head of Division Chiropractic, Head of the Welsh Institute of Chiropractic, Department of Professional Education and Service Delivery, Faculty of Health, Sport and Science, University of Glamorgan, Wales, UK
Introduction It has been stated that chiropractic is a large and well established healthcare profession, particularly in the United States, where it has made substantial gains in terms of educational standards, credible research contribution, legislation and market share.1 The profession has also made considerable progress in other jurisdictions, most notably the UK and parts of Europe in terms of statutory regulation, university based education and postgraduate development. Nevertheless, the profession is facing a number of professional issues that may threaten its future progression despite these local achievements; moreover, the situation is not being ameliorated by the fact that the profession is still viewed by many as somewhere between mainstream establishment and complementary and/or alternative (CAM) practice, a sort of ‘‘no man’s land’’, despite achieving many mainstream characteristics such as statutory legislation and publicly funded educational programmes. As a result, conflicting views have arisen between the public, the healthcare community and the chiropractic profession, which may have contributed to this current lack of identity and confused image.2 To be honest, the chiropractic profession doesn’t do itself any favours, particularly when it chooses to disregard the impact associated with perpetuating outdated principles conceived in the 19th century, and the influence this has on its current professional standing. Embracing modern health science would be one crucial way forward to shift public opinion and our status in the health care community. At the time, Haldeman, Meeker and Mootz1 proclaimed that the next decade will determine whether or not the chiropractic profession will be granted mainstream status and fully integrated into all healthcare systems or, to the contrary, continue to be labeled as a CAM profession with the inherent stigma and prolonged skepticism attached to this label and those who practise under this banner. Since 2002, the chiropractic profession has accomplished a great deal, but is a long way away from realising full integration in national healthcare systems and accepting responsibility associated with mainstream status. There are many reasons for this current state of affairs.
Reflection Recently, Murphy et al. (2008)3 have maintained that, despite its longevity, the chiropractic profession has not achieved its full potential and has failed to demonstrate the evidence required for future sustainability within the healthcare environment. Their analysis is focused on issues within the United States, but some of their concerns transcend boundaries and may threaten future professional advancement along with respect and credibility within the healthcare community and society generally. The numbers speak for themselves and according to Lawrence and Meeker (2007),4 chiropractic utilization (market share), for low back pain in
Lectures
103
the US varies from 6% to 12% of the population. More alarmingly, Tindle et al. (2005),5 report that the percentage of the population in the US utilizing chiropractic care has actually diminished from 10% between 1992 and 1997 to 7.5% from 1997 to 2002, which in some way may indicate chiropractic’s diminishing position in the healthcare league table and a trend towards a dwindling share of the market. This may be a cyclical pattern at the expense of the ascendency of more ‘‘popular’’ interventions but, at the end of the day and all things considered, there are clear signs that the profession may be facing a downward spiral and a crisis situation that requires immediate attention.3 The question then arises, ‘‘Can the chiropractic profession overcome its problematic past to become an established and respectable mainstream profession within the foreseeable future?’’ This is a very complex question and it has been suggested that, in order for the profession to turn this around, succeed and overcome an unstable market share, poor social image, lack of public confidence and low status among other health professions, it must consider making appropriate and immediate changes as part of a clear forward thinking strategy similar to those adopted by the podiatric profession in the United States.3,6 The profession urgently needs to create a vision for itself and establish a cultural authority as non-surgical, musculoskeletal spine specialists, providing a model of care that is supported by a substantial evidence base, coherent with and benchmarked against national health system governance and clinical care pathways. The chiropractic profession, if it wishes to be a part of mainstream health care, cannot be all things to all people and promulgate outdated and untested clinical principles and expect to be taken seriously by an informed society. It must make critical choices and unified decisions about its identity and where it wants to fit into the milieu of health care. This may necessitate narrowing the system(s) we treat and expanding our therapeutic scope, thereby forcing us to reflect on and accept the limits of our professional influence to secure a future. This view does not reduce, nor should it impact on, our aspirations regarding our primary contact role, but the chiropractic profession has to demonstrate that it has the capability of re-defining itself as a responsible and modern profession underpinned by contemporary healthcare values and science. Murphy et al. (2008)3 have identified a number of key areas for consideration as part of a strategy to focus on the future of the profession, including:
Public health participation Educational standards & expansion Identity/cultural authority Professionalism & ethical behavior Social responsibility.
These authors have also reflected upon the development of the podiatry profession in the United States and their successful integration and wide utilization within the healthcare system.3 The podiatry profession as a whole has been very successful in these areas, whereas the chiropractic profession has simply not even come close, due to its lack of unity and unwillingness to establish a suitable science based identity. Unification of the profession is as remote today as it has ever been and is, in some ways, responsible for the lack of progress Chiropractors are situated in the healthcare community at a primary contact level, providing care for their patients and, as a result of this favourable position, they should actively embrace important public healthcare initiatives instead of denouncing extremely successful public health measures such as vaccination. It would be a different scenario if chiropractors were qualified immunologists with years of research and practice experience in these matters; however, employing theories that are, at best, outdated and weak to substantiate these claims is no longer tenable and only adds to the professional embarrassment that we face, along with continued isolation and uncertainty. Participating in public health schemes and health promotion will enable chiropractors to work alongside other health professionals and agencies, giving chiropractors an opportunity to provide their patients with information and strategies to deal with longstanding issues such as tobacco use, obesity, poor diet and physical inactivity and the consequences these have on overall health. Educational curricula need to be flexible and designed to accommodate these competencies.
Solution/strategy It could be argued that prolonged isolation and impaired integration are the greatest obstacles for the profession to overcome for its future growth within healthcare delivery. The profession works in relative isolation and has yet to create a clear model for its services. Integration would come at a cost, but this would be a huge investment in future advancement. No doubt there will be many who may object that the profession will
104
Lectures
lose its identity and be forever subsumed by the medical establishment. It is my view, that this is simply paranoia and myth. There are numerous examples throughout the international community where chiropractic has integrated effectively. Denmark and Switzerland are two very good examples of professional integration in both education and national health infrastructure; nevertheless, there needs to be more expansion and sustained development in these areas. This was featured at the recent World Federation of Chiropractic (WFC) Biennial Conference in Montreal, Canada (2009), where a few very high calibre projects were highlighted including: Chiropractic student rotations in veterans’ medical centre/hospitals in the US as part of their undergraduate education Government policy changes in Ontario, Canada requiring all health sciences students to have formal interprofessional education to better understand all healthcare professionals and encourage collaboration The Harvard Medical School project, integrating various complementary services, including chiropractic, and resulting in greatly improved patient outcomes Details of the full integration of chiropractic services within the core sports medicine team for the Vancouver Winter Olympic Games in 2010.7 This conference also brought together eight chiropractic Research Chairs at leading Canadian Universities, who are conducting their own research and supervising other chiropractors pursuing PhDs, illustrating what can be achieved when individuals are committed and supported financially to realize their aspirations. The Chiropractic Research Unit at the University of Glamorgan was included in the UK National Research Assessment Exercise (RAE) in 2008, and its work successfully judged against national standards with other university research units. More importantly, chiropractic undergraduate education must become integrated within the higher educational infrastructure at university level, which brings access to public funds, research opportunities and staff development. The chiropractic schools in the US have failed to achieve this objective8; however, there are increasing numbers of university based programmes in, for example, the UK, Denmark, Spain, Switzerland, Mexico, Brazil, Malaysia and Australia. Despite the shortcomings of residing in a large public institution, the overall benefits of moving away from private educational institutions are far more important. Currently, there are 39 chiropractic educational institutions worldwide, which possess both international and, in many instances, national accreditation by a competent authority. Of these institutions, 16 are placed within a university and, with one exception, all of these are outside the United States. In my opinion, public funding will have a significant impact on chiropractic education, and will no doubt ensure a solid future for increasing student recruitment. In addition, there are a number of other benefits associated with the state university system including access to specialist lecturers, subject expertise, expanded library access, sport facilities, housing and other potential contacts related to the national healthcare system that will benefit chiropractic students and their educational development. The profession must move in this direction to enable student access to high quality education and minimise the excessive financial burden, which may influence individual practice style and ethical behaviour following graduation. Chiropractic students should be supported in as many ways as possible to achieve their professional goals and future career. A recent study of US chiropractic institutional curricula revealed programmes which, on average, consisted of 4820 h of both classroom and clinic training, which exhibits considerable commonality between chiropractic and medical education.9 The greatest identified difference between medical and chiropractic educational programmes appeared to be in the extent and diversity of the clinical training.9 Medical education included more than twice as many hours in clinical training than chiropractors in the US1 and, in my opinion, this remains a significant flaw in our educational programmes and a need for future development as the profession strives towards a more integrated role in educational delivery. An integrated model exists at the University of Southern Denmark and at the University of Glamorgan; we have pioneered a pilot student placement programme in two local hospital trusts near the university, as a direct result of perseverance as well as our contacts in our Faculty of Health, Sport and Science. There are plans to roll the programme out fully and expand the scheme within the curriculum. Modern health care delivery is integrated, patient focused and multidisciplinary in nature; therefore, it is imperative that chiropractic undergraduate education expands and develops sustainable inter-professional links within the wider healthcare community to prepare graduates for this integrated care delivery model. The purpose of such collaborations would be to broaden student experience, enrich the undergraduate programme and interact directly with mainstream healthcare professionals as part of the healthcare team.
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This development will require graduates to demonstrate proficiency in a new knowledge base and clinical and communication skills. There is no doubt this will pose a significant challenge for most chiropractic undergraduate institutions, as there are very few models where the infrastructure and links are sufficiently well developed to be fully integrated with other health professional or medical training. Curricula would require re-organisation and planning to accommodate this element of training. Historically, chiropractic education has developed in isolation from the rest of the healthcare delivery system. As a consequence, any collaborative relationships tended to be developed locally and poorly coordinated. It is my opinion that, in order to cultivate this type of inter-professional education, the chiropractic profession must establish and adopt a modern professional identity that is reflected in the educational outcome. Secondly, the profession must determine its role and identity in the healthcare delivery system compatible with current health care evidence based philosophy. Such models currently exist in Europe, South Africa and Australia and have eclipsed the private institutional model in North America. The financial burdens associated with private education are prohibitive for prospective students and their families; for sustainable growth and credibility, a university based model must develop internationally for any opportunity to develop these important collaborative links. Collaborative networking and expansion of the undergraduate experience is an educational challenge for chiropractic educators. Efforts must focus on purpose and appropriate learning outcomes. The healthcare environment has changed dramatically and our undergraduate programmes must reflect contemporary, inter-disciplinary approach to patient care. Masters level education is now the model of choice for undergraduate education, whether it is the Bologna ‘‘3 + 2’’ model or the integrated masters programme. The key to the integrated masters is the ‘‘masterliness’’ element, which raises the level of learning, particularly during the clinical training aspect of the degree. At this point, students must be selfdirected, innovative and original in being able to tackle complex clinical problems and make appropriate decisions regarding patient management. In order to achieve this, and even though students are under supervision during this process, they must exhibit specialised knowledge, ethical behaviour, complex problem solving and effective communication which constitute activities consistent with in clinical practice. It is this level of ‘‘supervised experience’’ that gives this the ‘‘masters’’ element. Students also participate in an original research project as part of the ‘‘masters’’ process to develop independent inquiry, which is a mandatory component of the degree. This process encourages a research and scholarly active culture within the programme and drives staff and curriculum development. The profession must also establish its cultural authority in order to create a useful role and identity and purpose within national healthcare systems and not be regarded as an alternative competing profession. The chiropractic profession needs to build on its obvious strengths and address its weaknesses in order to sustain a level of success. For example, the Spine Care Model as described by Nelson et al. (2005)6 suggests that chiropractic should be a neuromusculoskeletal specialty, with particular emphasis on the spine and consists of the following elements:
Chiropractic as a portal of entry (POE) — physician/provider. Chiropractic as a willing and contributing part of the evidence based healthcare (EBHC) movement. Chiropractic as conservative/minimalist healthcare provider. Chiropractic as a fully integrated part of the healthcare system, rather than as an alternative and competing healthcare system.
Nelson and his co-authors presented a cogent debate regarding the role and identify of the chiropractic profession, which could essentially be classed as a landmark paper as it describes a contemporary model of how the chiropractic profession should develop its own cultural authority within mainstream health care in the future. It is clear, coherent and professionally defensible. The profession needs to define for itself what its parameters are and how to validate these, despite the mitigating forces both within and external to the profession that will impede such progression. Nelson et al. (2005)6 proclaimed that the chiropractic professional identity should be based on spinal care as the defining clinical purpose and chiropractic should be integrated into healthcare provision locally with implementation of accepted high standards of professional ethics. They addressed a number of issues and presented clear and concise statements for adopting this model. They unmistakably stated that, ‘‘Cultural authority is granted by society based on recognition of a professional group’s competency and legitimacy with respect to the domain over which it professes dominance. With cultural authority comes a certain degree of autonomy and privilege.’’ This is profound,
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particularly with respect to professional credibility, and the easiest way to diminish trust and the level of cultural authority is to continue to embrace unethical professional activities. Cultural authority means that one has the right to define truth. Thus, if we can define for the public that chiropractic care is a safe and effective intervention and they accept this fact, then the profession can proclaim cultural authority. This is the heart of professional credibility because one could ask the question, as Nelson et al. (2005)6 have plainly stated, ‘‘Why is modern evidence largely being ignored by policy makers and the access to chiropractic care being impeded by arbitrary obstacles?’’ The proposed model will assist the profession in integrating into mainstream health care whilst maintaining its own identity. This is an important consideration at this point and it strongly recommended that all chiropractors read and digest this publication if we are to move forward. What better place to be than to serve the public as a unified profession providing integrated conservative interventions as spinal healthcare specialists supplying services that society want and need.7
Conclusion There is no questioning the fact that the chiropractic profession has made substantial progress in educational development, research and professional practice on a global basis but the achievements are not uniform across all jurisdictions. Further progress, particularly integration into healthcare systems as a credible, respected and widely utilized profession, will require a concerted and unified effort based upon an agreed strategy employing the example set by the podiatry profession in the US as a useful guideline. There is an enormous opportunity for the profession to become valued, non-surgical spinal care specialists offering expertise in diagnosis, treatment and patient management in order to gain any sense of acceptance within the wider healthcare community. This would have to be a long term strategy and the profession would have to be united in this endeavor. The future has to be led by the sensible majority, who want to integrate their services to best serve their patients and the public to secure a prosperous future. This presentation outlines the problems facing the profession; discusses achievements to date and frames a strategy to methodically work towards achieving these aspirations and goals.
References 1. Haldeman S, Meeker WC, Mootz RD. Back to basics...The state of chiropractic research. Top Clin Chiropr 2002;9(March (1)):1—13. 2. Meeker WC. Public demand and the integration of complementary and alternative medicine in the US health care system. J Manipulative Physiol Therap 2000;23:123—6. 3. Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? Chiropractic Osteopathy 2008;16:10. 4. Lawrence DJ, Meeker WC. Chiropractic and CAM utilization: a descriptive review. Chiropractic Osteopathy 2007;15:2. 5. Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medicine by US adults: 1997—2002. Altern Ther Health Med 2005;11(January—February (1)):42—9. 6. Nelson DF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, et al. Chiropractic as spine care: a model for the profession. Chiropractic Osteopathy 2005;13:9. 7. Chapman-Smith D. The Road to Integration. The Chiropractic Report 2009;23. 8. Wyatt LH, Perle SM, Murphy DR, Hyde TE. The necessary future of chiropractic education: a North American perspective. Chiropractic Osteopathy 2005;13:10. 9. Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education. Altern Therap Health Med 1998;4:64—75.
doi: 10.1016/j.clch.2010.02.018