May 2006

Building an evidence‑based chiropractic research culture...

How to transition without significantly de-stabilizing the profession

by Robert H. Blanks, PhD, President of RCS

Our attention has been drawn recently to the economic plight of the big three US auto manufacturers. Apparently, a major part of the problem is the cost of the retirement and benefits packages. Of these, health care costs are the most crippling. Chrysler's annual health care bill is $2.3 billion, or the equivalent of $1,400 per vehicle according to a recent article in The New York Times. Chrysler's health care cost have risen 100% since 2000 and it is estimated that health care costs nationwide will rise 13% per year through 2020. In response, Chrysler announced that beginning next year workers will pay an average of 31% of the health care coverage (up from 27% last year) and executives and retired workers will pay even more. The trend toward health care cost‑cutting has become all too familiar.

In my research article last month, I reviewed some of the literature on the health and economic benefits of long‑term chiropractic care for seniors. Clearly, more research will be required to thoroughly evaluate the health‑ and cost‑benefits of care for all age and ethnic populations. The task at hand is enormous given the lack of research infrastructure in the profession.

In a recent report ‑‑ the ACC Strategic Plan Development Subcommittee for the Development of the Profession's Research Infrastructure ‑‑ one of the major concerns expressed was that "The culture of the chiropractic profession has not matured to the level of looking to research for answers to questions related to the reliability and validity of chiropractic assessment procedures or treatment effectiveness." Based upon this and other concerns, the ACC Subcommittee made a number of important recommendations to build the research infrastructure in chiropractic with milestones impacting the colleges, CCE, FCER and other agencies through year 2008 and beyond. We are rapidly approaching these deadlines.

Some progress has been made along these lines for improving research funding in the colleges, development of evidence‑based curriculum, establishment of evidence‑based clinical practice guidelines, etc. The question is, will these changes be sufficient to advance the research culture of chiropractic in time to solve some of the problems with our national health care crisis? Perhaps an even more important question is whether in growing the evidence‑based chiropractic research agenda there will be a systematic destruction of the basic tenets ‑‑ art, philosophy and science ‑‑ of the chiropractic profession.

The term "genocide" is a morally repugnant term used to describe the annihilation of one racial group at the hands of another. The actual definition is much broader and covers "... the deliberate and systematic destruction of a racial, political or cultural group" ("Webster's Ninth New Collegiate Dictionary," 1988).

Cultural anthropologists view health professional training as a form of enculturation. Members of a given health profession are a subculture that share a common language, beliefs, values and behaviors. They also have common political motives related to protection of scope of practice, conditions of patient acceptance, boundaries, ethical conduct, etc. Chiropractic is rich in politics and philosophy, and it has several well‑entrenched and often opposing factions.

There is no doubt that all health professions are being pressured to produce research documentation to support all health claims and services rendered. Evidence‑based health care is thought to be the battle cry to characterize the need for the culture of evidence in support of the discipline. Chiropractic will be no exception.

The article you're now reading is an appeal for unity within chiropractic. As an outsider who has studied the profession for almost a decade, I would submit that there is a need to cultivate the middle ground, particularly as we transition to the "new chiropractic (evidence‑based) research culture." The research agenda needs to be broadly defined and all‑encompassing, not simply focused on one particular perspective (e.g., condition‑based, subluxation‑centered, etc.). Issues of fairness and scientific methodology need to be followed so that the many parallel research efforts create a productive (and not destructive or, worse yet, genocidal) and efficient working environment.

Dorothy Law Nolte was a brilliant writer and family counselor who wrote an inspirational poem on raising children called "Children Learn What They Live." This poem has been circulated worldwide to millions of readers, anthologized, and translated into 18 different languages. Considered timeless wisdom by some and undiluted treacle by others, Mrs. Nolte's poem relates not only to raising children but also to training students and educating patients. As you read this poem substitute the word "students" or "patients" for the word "children."

"If children live with criticism, they learn to condemn
If children live with hostility, they learn to fight
If children live with fear, they learn to be apprehensive.
If children live with pity, they learn to  feel sorry for themselves."

But, the poem continues:

"If children live with encouragement, they learn confidence.
If children live with tolerance, they learn patience.
If children live with praise, they learn appreciation
If children live with acceptance, they learn to love."

In building the research infrastructure in chiropractic, I suggest that we must refrain from promulgating criticism, hostility, fear and pity. The ideal would be to revise the culture to create understanding among the groups within chiropractic and promote the new research agenda through encouragement, tolerance, praise and acceptance of research as a means to advance the profession. Hopefully, in this way, the next generation of chiropractors will all be scholars capable of making evidence‑based decisions and participating in research and other scholarly activity. It's also hoped that as health educators, our patients fully understand the value of maintaining a healthy lifestyle and their personal responsibility for contributing to their health.

Chiropractic is the third largest health profession in America (behind medicine and dentistry). Unified, the profession should be able to contribute substantially to solving many of the health care problems currently facing the country and the world. This should be possible when chiropractic research, as pointed about by the ACC subcommittee, is applied in a major way to answer "...questions related to the reliability and validity of chiropractic assessment procedures or treatment effectiveness." Now is the time to make the difference.

(RCS co‑founder and President Dr. Robert Blanks is Professor in the Department of Biomedical Sciences at Florida Atlantic University and a past Professor of Anatomy and Neurobiology at the University of California, Irvine. Prior to this he spent two years at the Max Planck Institute for Brain Research in Frankfurt, Germany and two years in the Department of Anatomy at Harvard Medical School. Dr. Blanks is on the Advisory Board of the International Spinal Health Institute, is a Board Member of the Council on Chiropractic Practice and is actively involved in chiropractic research. To learn more about health outcomes research and RCS, call 800‑909‑1354 or 480‑303‑1694.)