April 2006

Can you handle the truth?

by Dr. Matthew McCoy, vice-president, Research & Clinical Science       

"The truth. Malice may attack it, ignorance may deride it. But in the end there it is." ‑‑ Winston Churchill

In the movie "A Few Good Men," Tom Cruise presses Jack Nicholson to tell him the truth throughout the movie and in the final climactic scene Nicholson barks back: "You can't handle the truth" and proceeds to lay out all the truth Cruise was seeking and then some. Cruise is visibly shaken for a brief period as he begins to hear and digest the raw reality presented to him.

We face a similar situation within the chiropractic profession at the current time and I predict we're going to see more of it in the coming months and years as the profession attempts to clarify how it feels and where it stands on certain issues.

All too often, chiropractic is criticized as an "unscientific" discipline, lacking empirical research to validate the assertion that vertebral subluxations have an adverse affect on the human nervous system, on general health and well‑being and by extension, society as a whole. Unfortunately, this criticism is not taken seriously by the leadership of the profession ‑‑ especially the faction of the profession that should be on ultra high alert regarding this issue ‑ the subluxation based portion of the profession. A leader in the profession recently wrote the following regarding how to eradicate the widespread opposition to chiropractic:

"...the chiropractic wellness lifestyle will prove itself, especially if we get the right people to pay attention."

In over 100 years, the chiropractic wellness lifestyle has not proven itself other than to the less than 7% of the population using it. Making matters worse is that the percentage of the population that are seeking chiropractic services is decreasing ‑‑ not increasing. This is occurring at the same time that enrollment in chiropractic colleges is down 40% and while other professions are encroaching on our turf.

Chiropractic is not going to prove itself. A concerted effort must be made to demonstrate the health benefits that chiropractic imparts to individuals and to society as a whole. And that effort must be research‑based. Once the research supports our contentions then we can get "the right people to pay attention." Anything else is a fairy tale.

So just who is actually doing something to provide the needed evidence we are in such desperate need of?

Research and Clinical Science (RCS) for one.

RCS has set out on the systematic study of the epidemiology and global burden of vertebral subluxation. This study is being carried out by individuals and groups with a worldview towards chiropractic that is consistent with the theory that subluxations pose a hindrance to the fullest expression of life. The results of this type of research can then be used to drive policy, not only in health care, but in education and other sociocultural arenas.

RCS has developed a model of training and linking chiropractic practitioners, researchers and teaching institutions through a centralized network and a web‑based, electronic data repository in order to provide comprehensive, consistent and comparable information supporting such a worldview on the global burden of vertebral subluxation. This is not another low back pain study!

During this process of clarifying conflicts it is wise to remember that there is truth and there is that which is not the truth. While it is sometimes seems less painful to bury your head in the sand and ignore the reality of the situation the truth is ‑‑ ignorance is not bliss. I'd like to define some of the "truths" facing us as a profession right now.

Truth #1: The ACC Paradigm

While this was and still is billed as the great uniting document for the profession it does not appear that everyone is living up to their part of the bargain. Much has been written about the significance of all our College Presidents getting together and agreeing on some basic fundamental issues and the subsequent endorsement of it by all national and international organizations. It is, in fact, agreement on the ACC Paradigm that is a mandatory requirement for participation in the National Chiropractic Leadership Forum (NCLF).

The bottom line with the ACC Paradigm is the spectrum portion of the document. At one end you have the straightest of straights and at the other you've got a DC who is just a scope of practice change away from being an MD. The beauty of the document lies in the implied and often stated declaration that everyone at the extremes and everyone in‑ between is "safe." The straights are safe because the document allows for a strict subluxation only practice and the mixers are safe because the document allows for the implementation of broad diagnostic and treatment procedures.

At the NCLF meetings the World Chiropractic Alliance was clear that it could live with and endorse the document because of the "live and let live" message. Unfortunately everything is not always what it seems. In truth, the portion of the spectrum that repeatedly gets attacked by state boards, malpractice and the broader scope devotees are those chiropractors that choose to limit their practice to the analysis and correction of subluxation. This happens even in situations where the chiropractor has consent and understanding from the patient that this is their sole practice objective.

The truth is that rarely will you see a state board attempt to sanction the license of a broader scope practitioner. The further truth is that rarely will you see a state Board attempt to revoke the license of a practitioner using gross, non‑specific manipulative procedures to treat pain syndromes, but you will see subluxation‑based chiropractors who use evidence based procedures being called before them and accused of practicing unscientific and unproven methods.

I've been involved in expert witness work for some time and keep thinking that I have seen just about everything. But I get proven wrong on a daily basis. The "experts" for the prosecution typically portray subluxation‑based chiropractors as inept, uneducated, unscientific public health menaces. Typically they are painted as snake oil salesmen only interested in seeing how many visits they can get out of a patient. These opinions are always supported by experts who are members of "bigger" and more "scientific" organizations, as they like to pretend.

The truth is that when the light is shone on them, they lack the evidence and they are the menaces. One recent attack on a subluxation based chiropractor involved using "experts" who not only maintained that there was no identifiable health benefit from subluxation reduction in children, but that subluxations in fact do not exist.

Imagine explaining to a judge and jury the intricacies of immobilization degeneration, Wolf and Davis' Law, neuroplasticity and the finer points of connective tissue rheology. Another involved a chiropractor using Network technique and the allegation that it was not "scientific." When it was shown that Network has more science behind it than the diversified technique promulgated by the Board members it was another example of "you can't handle the truth."

These are not isolated cases. They are happening everyday to chiropractors throughout the world and the actions are fueled by those within the profession that cannot "live and let live." This is why clinical outcomes research is so crucial.

Truth #2: Rodney King syndrome

We're hearing the pleas of "can't we all just get along" from many leaders in the profession these days and I suspect that it will increase. There are even those leaders who refuse to talk or work with other organizations unless and until they succumb to their will, see things their way and merge. I avoided those guys like the plague in the sand box and schoolyard and I avoid them now as adults.

That's not to say I don't understand the yearning to be "one" and have unity. I've gone through all the bleary eyed possibilities should this happen. But perhaps our divisions are not as bad as we make them seem to be. Perhaps chiropractic's divisions are actually evidence of professional vigor. After all what is the alternative? That our divisions are the result of some arcane misunderstanding? I doubt it and the more I talk to students, practitioners, and especially practitioners defending themselves for their lives, the more I am convinced that real differences divide chiropractors and that our history is dignified by our serious quarrels. The profession is not split because you can't split rotten wood.

Truth #3: The profession has spoken

The notion by some that this or that organization or group represents the profession or even a substantial segment of the profession is the height of denial. On a good day only about 10,000 chiropractors belong to any national association so the vast majority of chiropractors have already voted ‑‑ with their feet and their apathy.

The profession has also spoken in the recent study titled: "How Chiropractors Think and Practice." According to this study we're all pretty much doing the same thing: adjusting our patients for subluxations, providing wellness care and teaching lifestyle modification to assist in the healing process. The study pretty nearly mirrors the ACC Paradigm. But again the truth is that in practice we have the self appointed experts who say subluxations have not been proven to exist, that a practice based on wellness is not evidence based and that you must practice to the absolute limit of your licensed scope.

Truth #4: Solutions and problems

The profession is currently facing some serious problems. RCS offers a number of solutions and remains committed to working with those groups and individuals that wish to work towards common goals aimed at overcoming these problems. We believe the solution is in the evidence and we have developed an ambitious research project to gather that evidence.

The longitudinal time‑series population‑based clinical outcomes study established by RCS is a systematic and ongoing analysis of the clinical indicators (outcome measures) that characterize vertebral subluxation. This process is designed:

1. To evaluate and document outcomes information, the health benefits, risks, utilization, and efficacy of approved and existing chiropractic procedures.

2. To provide a measure of continuous quality assurance and improvement.

3. To evaluate long‑term benefits and risks of chiropractic care.

4. To provide scientific evidence for efficacy in large populations of patients under chiropractic care.

5. To allow comparison of the risks and benefits of several available techniques used to manage the same condition.

6. To identify disparities in health status and use of chiropractic health care by race/ethnicity, socio‑economic status, region, and other population characteristics.

7. To monitor trends in chiropractic health care delivery.

8. To support health research.

9. To provide information for making changes in public policies and programs related to chiropractic.

10. To evaluate the impact of health policies and programs related to chiropractic.

RCS can not accomplish this alone ‑‑ it needs practitioners just like you out there in the trenches, caring for patients and collecting the clinical data so vital to advancing the agenda of subluxation based chiropractic.

Truth #5: The Principle is not ours

I encourage you to think of the fullness of time when considering decisions being made today about the direction and focus of research in the profession. What will the profession look like 10, 20 or 50 years from now? As difficult as it might be for some to hear, the principles the profession is based on really do not belong to us. They belong to humanity and those groups and individuals that demonstrate the best stewardship of those principles will be given the honor of providing those benefits to humanity.

Will it be the chiropractic profession that is releasing the imprisoned impulse 50 or 100 years from now or will it be some other provider? I believe the answer lies in a group of dedicated individuals that have a strategy based on what is best for humanity and who are guarding the honor of carrying that benefit to them.

(Matthew McCoy, D.C., vice‑president of RCS, is Editor of the Journal of Vertebral Subluxation Research and Director of Research at Life University College of Chiropractic. He is a founding board member of the Council on Chiropractic Practice currently serving as its Vice President and Chairman of the Guidelines Committee and Vice Chair of the Research Committee. He is the Representative of the CCP for the National Chiropractic Leadership Forum and is the WCA liaison to the Institute of Medicine's Committee on Complimentary and Alternative Medicine. As chair of the World Chiropractic Alliance's Chiropractic Advocacy council he assists doctors in defending themselves in malpractice actions and board complaints. He has served as an expert witness and consultant in numerous state board actions, malpractice cases, peer review, insurance and IME issues. He can be reached at info@rcsprogram.com)