| | Reflections on Cultural Authority, CAM and Chiropractic - from the ACC-RAC 2008 Conference | |
Summary: Peter Amato and
Steve Szydlowski, DHA, MBA, consulted on the integrative wellness
center that would be associated with the 313 acre Deep Lake sustainable
community and resort envisioned for rural Michigan and reported here in
December 2007. The two, founder and CEO, respectively, with Inner Harmony Group, faced significant challenges based on the Deep Lake location, population and weather. This Integrator double-interview guides you through their process in creating a combined integrative wellness center-spa strategy.
Background: The Limbo Profession
 The limbo profession
Look at us, they say: We're licensed in 50 states, covered (partly at least) by Medicare and by most employer health plans, credentialed and practicing in the Veterans' Administration facilities and making headway in other Department of Defense initiatives. We're at the table, in DC, working hard, continuously lobbying, taking on on HMO exclusions, making headway year by year, busting back the AMA when they encroach on our rights to make a living, advancing continuously even against continuous attacks from the mainstream.
There's the rub, and the limbo for chiropractic. Despite chiropractic's
advances, the field remains the licensed natural healthcare discipline
that conventional medicine most loves to hate. In my own examination of hospital-based integrative clinics,
only a fraction - 5 of 27 (19%) - had a chiropractor on staff. By
comparison, massage therapists were in nearly 100%. Licensed
acupuncturists, newer players in the field, were in 65%. Naturopathic
physicians, despite only having licensure in a minority of the states
in which the integrative clinics were located, were in just one fewer
(4) of the clinics. And this paltry inclusion comes despite the fact
that chiropractors are better integrated into the payment system and
have relatively high utilization by the very consumers to whom such
clinics are seeking to appeal. Why the short shrift? Typically an
orthopedic surgeon who effectively has veto power in the system threatens to hold
up the whole integrative undertaking if a chiropractor is involved.
In short, chiropractic has, frequently, successfully, fought its way
in. However, chiropractic has much less often been invited to the table. So the
question was front and center at the 2008 ACC-RAC: How can "cultural
authority" be established by chiropractic?
 1. A starting place for gaining authority: invite more outsiders to the conference
I have worked closely with many chiropractic leaders over the past decade. Lou Sportelli, DC, and Tino Villani, DC have supported many aspects of my work, including this newsletter. ACC's executive director David O'Bryon, past ACC chair Reed Phillips, DC, PhD, and the immediate past chair of the profession's accrediting agency, Joe Brimhall, DC, have been among my close colleagues since 2004. We've helped organize the National Education Dialogue to Advance Integrated Health Care: Creating Common Ground and the Academic Consortium for Complementary and Alternative Health Care.
It was through those connections that I was invited to speak, a talk
on our work with other disciplines, conventional and "CAM," to enhance interdisciplinary collaboration. In short, some of my best
friends are chiropractors. Yet for all this connectivity, I must
report, sheepishly, that the experience of being at ACC-RAC with these
professionals, educators and scientists opened my eyes significantly to
the strength and, well, authority of the profession. I met many fine, earnest
professionals (and a happy number of very enjoyable souls, not necessarily a separate category), all working
hard to better their profession. In a context shaped by prejudice (I
received bias against chiropractic from my Bostonian Mom),
connection is useful. Chiropractic would serve itself to invite more
outsiders to their ACC-RAC meeting.
 NYCC campus
In this culture, one gains authority by having a golf course on campus. New York Chiropractic College
has one. Well, 9 holes. More important, authority may be gained through connectivity.The upstate New York institution, located on
3200 acres, also boasts a Department of Acupuncture and Oriental
Medicine (AOM). Jason Wright, LAc, is president of NYCC's
faculty senate. A medical doctor is on staff in the principal NYCC
teaching clinic. In addition NYCC has: relationships with 5 separate
Veterans' Administration hospitals; participation in a Blue Cross hospice care program; partnerships with 2 community clinics; and a further relationship with the Monroe Community Hospital. I learned all this as a quick download from Frank Nicchi, DC, NYCC president. Nicchi is among chiropractic leaders who are not CAM-adverse. A decade ago he began attending the Harvard conferences when the
"integrative medicine" discussion began. Nicchi sees
value, and a potential for enhanced cultural presence, in chiropractic
affirmatively linking with the other, philosophically-aligned,
health-oriented natural healthcare disciplines.
 Claire Johnson, MSEd, DC
One tool of authority available to the chiropractors for the past 20 years is The Journal of Chiropractic Education,
published by the ACC. No other "CAM" field - naturopathic medicine,
AOM, or massage - has a publication dedicated to fostering and
publishing the scholarly and research writings of its educators. In Volume 22, Number 1, researcher Claire Johnson, MSEd, DC and editor Bart Green, DC, MSEd published a data-based evaluation of the articles in JCE
since it was founded. The greater part of the authority in the piece
was its honesty. Of the total of articles, 66% were found to be
non-data in nature. A minority of schools were responsible for a vast
majority of the publications. Interestingly, there appeared to be a
strong correlation between the schools which had a high level of publications and those which have extended their institutions in the last decade to become multidisciplinary by adding AOM and/or naturopathic medicine programs. In
short, interest in research may be correlated with interest in
multidisciplinary activity. The authors recommend that in the future
"more efforts and resources [should be] dedicated to data-driven
studies."
 Authority through integrative clinics
One non-data article in the current JCE, by James Lehman, DC, MBA and Paul Suozzi, PhD,
suggests that a great way for chiropractic "to build higher cultural
authority" is to "found integrative centers of excellence." Lehman, a member of the faculty at the University of Bridgeport, figure that chiropractic might be able to integrate practitioners
without the biases in practitioner choices and therapies seen in many
conventional integrative clinics. Clinical educators with Northwestern Health Sciences University
(NWHSU) - a former chiropractic school which now has programs in AOM and
massage offers a model to back the theory. NHSU developed and runs an
integrative clinic on the highly regarded Natural Care Center at Woodwinds Health Campus. NWHSU is also in discussions about developing and managing a clinic with the Center for Spirituality and Health at the University of Minnesota.
Notably, interest in the UM partnership was stimulated by the
authority NWHSU gained through its modeling of a successful integrative
clinic at Woodwinds. Another indication of authority gained: NWHSU's work will be featured at the May 2008 Integrative Medicine for Health Care Organizations conference sponsored by Health Forum/American Hospital Association.
 Reed Phillips, DC, PhD, founding chair of the multidisciplinary educators' consortium
The guild warriors among the chiropractic profession are a powerful,
accomplished group. The internal line on their skill development is
that they learned from the best at guild politics: "the medics"
(AMA/MDs). Guild action is typically a dual visioned game: carve out
more territory for yourself from those above you while not forgetting
to slap down those at your heels and encroaching on your space. While
the independent practice of physical therapists
is particularly worrisome, the emerging licensed disciplines
representing massage therapists, AOM, naturopathic physicians and even
Yoga therapists can also be viewed as competitors. Chiropractors were
once virtually the one and only alternative; now there are increasing
numbers of others. Many chiropractors see the rise of these competitors
are led by an instinct to not align. Why help them? Yet other leaders, like O'Bryon, Phillips, Brimhall, Nicchi, Chuck Sawyer, DC at
NWHSU, and others see that there is a place here for chiropractic to
support and mentor some of these disciplines, while also learning from
them. Notably, the 2 retreats of the multidisciplinary Academic Consortium for Complementary and Alternative Health Care (ACCAHC), which I presently direct, were held in donated space at Southern California University of Health Sciences, formerly only a chiropractic college, and then Western States Chiropractic College. The
third, in May 2009, will be hosted by Sawyer's NHSU. Chiropractic
educators in ACCAHC have been profoundly positive and empowering
players.
 6. Guild Resistance to CAM Alliances: Are They Above or Below Us?
Sometimes, determining who it is okay to associate with, deciding who
is where in the pecking order of "cultural authority" can be
challenging. I had a conversation with a group of chiropractors at the
ACC-RAC who were more profession-aligned than educational
institution-aligned. They were strongly opposed to any chiropractic
affiliation with the "CAM" universe. One reason: To their
understanding, none of the other CAM fields had gained the authority of
chiropractic's status as a direct access practice. Therefore, to be
identified with CAM would, by association, only invite limits. In fact,
however, the assumption is not true, as I shared. First, the AOM
profession in New Mexico ("Oriental Medical Doctors") and Florida
("Acupuncture Physicians") has very broad practice rights. Inside the
AOM profession is a move to establish the field with more primary care
authority. More significantly, the naturopathic physicians have a
broader scope than chiropractors in all, or almost all, of the 14
jurisdictions in which NDs are licensed. Naturopathic practice
typically also has prescribing rights - an enviable scope inclusion for
any guild-oriented battler. This information, however, didn't seem to
change them. Don't bother me with the facts. My mind is made up. The animus behind the decision to not collaborate, right or wrong, resonates with that in integrative medical doctors who don't have the authority to put chirorpactors in their clinics: It'll be harder for me to do what I want with you connected.
 Partap S. Khalsa, DC, PhD, NCCAM program officer
One member of the closing panel of the meeting was the lone, licensed CAM professional on staff at the NIH National Center for Complementary and Alternative Medicine (NCCAM): Partap Singh Kahlsa, DC, PhD. Khalsa revealed that the new NCCAM director Josephine Briggs, MD,
had shared with staff, more than once, that she viewed manipulative
therapy as "low hanging fruit" for showing the value of CAM. Khalsa
then took a useful, unusual turn in his presentation on the
relationship of research to cultural authority. He described how
positive outcomes from a NIH consensus is the authoritative blessing at the NIH. Then he led
the assembled chiropractic leaders through the outcomes of a recent
such consensus conference on Vitamin D and bone health. For vitamin D,
there are hundreds or even thousands of clinical trials (my notes arE
not clear); for chiropractic there are 60-70 total on back pain,
chiropractic's leading area of research. Yet, other than for a few
conditions like rickets ("fair evidence" said Khalsa, adding: "I mean,
this is Herman Melville stuff ...'), most of the conclusions were
light, "inconsistent." The message: Put all your eggs in the NIH basket if
you wish to have a long-shot potential of gaining cultural authority at
some point after Florida is submerged by global warming,
 Mathew Kowalski, DC
The final panel also included the wizened integrative chiropractic commentary from Mathew Kowalski, DC, the lead chiropractor at the integrative clinic sponsored by the Osher Clinical
Center for Complementary and Integrative Medical Therapies.
Before Osher, Kowalski worked in a half-dozen health system-based
integrative settings, going back to 1991. He asked, rhetorically: "The
biggest common denominator in all the experiences on how I got it?" He
pauses: "I asked." There are 30 chiropractors credentialed into VA
facilities, 49 in US Department of Defense establishments, and 180 in
"civilian hospital based chiropractic practice." This totals some 260
out of 70,000 chiropractors. Why so few? Says Kowalski:
"(Chiropractors) just don't ask." Most MDs, he said, have never met a
chiropractor, "don't know how to use one and hospitals don't know what
to do with them." His conclusion, at this time, is that most of the
advances he has made are more from individual achievement than cultural
authority. I don't embrace chiropractic but I like this one chiropractor.
Chiropractors, says Kowalski, "need to educate [our] way in." More than
that, chiropractors need to keep the patient at the center of their
motivation for connecting with hospitals or medical doctors: "We need
to behave our way in." That stated, Kowalski noted that the Osher
position was the first in which the invitation did not come from his
own initiative. Said Kowalski: "There was some cultural authority
there."
Comments: This article begins and ends on the same
note: relationships. A year ago at this time I was just completing some
exciting work with a chiropractic organization. A colleague who is a
chiropractic educator and I recommended that the group take a series of
steps to support their members in developing networks of relationships
with other CAM and conventional providers. The visual was a simple
wheel with the chiropractor in the center, and spokes radiating out to
one each: massage therapist, primary care MD/DO, AOM professional,
naturopathic doctor, physical therapist, mental health/psychologist and
an orthopedic surgeon. The recommendation was that the organization
have an internal goal of supporting their members to each have at least
one of each of these practitioners with whom he or she felt comfortable
cross-referring. We said: Just explain to each that your patients want you to be connected. Do this and you will be playing against type. Others won't expect this of chiropractors. The organization has not, to my knowledge, moved on the suggestion, or anything like it.
At the end of my presentation on enhancing collaboration, which began with a description of chiropractic's limbo, I used a slide with a photo of a Roy Lichtenstein painting.
The blond has a telephone clutched to her right ear, her eyes are shut
from fear and a tear is falling from the left eye. She is saying: "Oh
no!! I can't believe I forgot to have a relationship."
Coda: Barack Obama's powerful speech on race March 18, 2008, is fresh in mind as
I write this. In the healthcare integration process,
it is the chiropractors who have had the harshness of the psychic stamp that, in race
relations, is paralleled by the experience of slavery on the soul of
the black man. The chiropractors were the chief targets of
the AMA's vicious anti-quackery campaigns in the 1960s-1970s. It is the
chiropractors who successfully fought the financially bloodying 12 year, David-versus-Goliath anti-trust
suit against the AMA which, with the chiropractic victory, ended the
worst of sanctioned, institutional medical bigotry in the United
States. It was the chiropractors who asserted a place on the bus of US healthcare, and refused to move.
In truth, for most of the last century of chiropractic's
existence, chiropractors were not allowed, by our culture's established
medical authorities, to have a relationship with them. Chiropractic learned to go it alone, come hell or high water, developing a learned ferocity through the pattern of received abuse. Yet now that profession's destiny, it's ability to gain authority, to fully serve clients, is inextricably linked to its ability to throw off that isolation through a patterned network of ongoing, essential relationships with other healthcare stakeholders. Secure inside that web, the gold ring of cultural authority will be in hand.
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