By Dr. Christopher Kent and Dr. Patrick Gentempo
The last 16 years have seen radical changes in chiropractic education and research. A growing number of chiropractic educators and researchers actively eschew traditional chiropractic philosophy. Modern students of chiropractic are often taught that chiropractic is a subset of medicine, specializing in the manipulative treatment of a narrowly defined array of spinal pain syndromes. Standards of care, insurance reimbursement guidelines, and state board policies are beginning to reflect this paradigm.
The authors suggest that this assault on traditional chiropractic principles and practices may be the result of organized effort on the part of a small but growing faction within the profession.
Chiropractic education
Major changes in chiropractic education were initiated in the early to mid 1970s. In an effort to obtain student loans and increased prestige, a number of chiropractic institutions sought federal recognition. The path followed was that of “three letter certification.” By getting three institutions which were traditionally accredited to accept credits from a chiropractic college, the latter could qualify for participation in federal student financial aid programs.
To achieve this objective, chiropractic colleges began replacing their D.C. faculty members with Ph.D. faculty in the basic sciences. The new Ph.Ds often knew little about chiropractic. Some expressed open hostility toward traditional chiropractic philosophy. The proliferation of Ph.Ds was viewed as a “necessary evil” to obtain financial aid. Few D.C.s were worried. D.C. faculty still controlled the clinical sciences as well as the administration of the colleges. They felt their influence would outweigh that of the nonchiropractor basic science faculty.
At this time, chiropractic colleges were accredited by either the American Chiropractic Association (ACA) or the International Chiropractors Association (ICA). Neither agency had status with the Department of Health, Education and Welfare (DHEW). Therefore, ACA or ICA accreditation provided peer recognition, but did not qualify the institutions involved for federal funding. Nor were chiropractic college credits readily transferable to traditionally accredited institutions. Some reports even branded D.C. degrees “spurious” despite the fact that these degrees qualified their holders to sit for state licensing examinations.
In an effort to “upgrade the image” of the profession, both the ACA and ICA decided to pursue federal recognition for their respective accrediting bodies. The ACA had the Council on Chiropractic Education (CCE) and the ICA schools were represented by the Association of Chiropractic Colleges (ACC). The latter is not related to the current ACC.
Heated debate — typical of the “straight” vs. “mixer” schism of the time — characterized the efforts of the two bodies to approach the federal government with one agency. An agreement was reached to defer the submission of formal applications for DHEW recognition by both groups. It was hoped that the two associations would be able to resolve their differences and approach the federal government with one agency. Despite this agreement, the CCE submitted an application and obtained approval while the ACC waited as promised.
No time was wasted persuading state boards to mandate that only graduates of CCE accredited colleges could apply for licensure. This was sold to the profession as a necessary step in “upgrading the image of the profession.” Those who resisted were branded intellectual dinosaurs. “How can anyone oppose improving chiropractic education?” they asked.
Student support was obtained by dangling the carrot of student loans. The fact that an alternative path had already been successfully employed to qualify for these programs was not disclosed. Students came to believe that “without CCE, we won’t be able to get loans.” D.C. and student dissenters who viewed CCE with a jaundiced eye were told there was no alternative, the DHEW would only approve one agency per profession — another falsehood. The source of these lies could not be clearly identified. They did, however, cause most of those involved to believe that there was no alternative.
For the ICA colleges, there seemed to be no practical alternative to seeking CCE status, since a growing number of states demanded that applicants for licensure graduate from a CCE college. As the treasurer of one college stated to a dissenting faculty member, “What else can we do? If we don’t get CCE status, we’ll lose so many students we may have to close.” The die was cast. The conspirators won round one.
CCE’s approach in the days immediately following DHEW approval was autocratic. “If they aren’t strict, we might lose DHEW approval, and then graduates couldn’t sit for boards in many states.” This, of course, was because of their own doing. Under the iron fist of the CCE, radical changes were instituted which affected the philosophical paradigm of traditional ICA colleges.
Early CCE standards demanded whole body diagnostic training. The rationale was that whole body diagnosis was required of a primary/portal of entry health care provider. This, however, was clearly not the case. A letter from DHEW clearly stated that in using the term “primary health care provider” there was “no intent to or authorization to change, or even define the authority, scope of practice, or function of the occupation concerned. [1]
CCE was not content to coerce dissenting colleges into joining. Free speech was cast to the wind, with CCE demanding “loyalty, advocacy, and support of the Council” from all sponsors. [2] The chiropractic profession soon experienced the “Stockholm syndrome” where captives befriend their captors.
In a move unprecedented in academia, CCE ostensibly stripped the once prestigious Ph.C degree from those holding this credential. CCE Educational Standards for Chiropractic Colleges stated that “CCE does not recognize Ph.C degrees or encourage their use.” Senior faculty holding Ph.C.s were humiliated by being ordered to stop listing this earned degree. No new Ph.C.s were conferred, and the credibility of the degree, and those holding it, was severely damaged.
CCE faculty/student ratio requirements necessitated the rapid hiring of large numbers of faculty. In the basic sciences, enthusiastic D.C.s were often replaced with Ph.D.s unfamiliar with chiropractic, and often inexperienced in teaching. Some Ph.D.s candidly admitted that they accepted their appointments out of desperation. At least one told first year students that as far as he was concerned, “chiropractic is a lot of bunk.” When students asked why they were paying tuition to be taught by an instructor who thought chiropractic was “bunk,” they were told to put up with it. “You want your student loans, don’t you?”
Of course they wanted their student loans! The students needed the loans to pay for the radical increases in tuition brought about by CCE mandated improvements. No one was about to tell them that they had access to such loans before CCE won government approval.
The type of student attracted to the profession began to change as well. At one time most chiropractic college applicants had a positive personal experience with chiropractic care, and wanted to share it with others. Many were “second career” students, who left successful jobs and businesses to study chiropractic. Some came from chiropractic families. This was soon to change.
Two years of preprofessional study were mandated, with specific course requirements that discouraged all but the most tenacious. Soon, instead of chiropractic zealots, it was not uncommon for the majority of students in a matriculating class to have never experienced a chiropractic adjustment. When these students were told by their professors that the profession they were entering was “unproven,” “bunk,” or worse, is it any wonder that many of them closed their minds to traditional chiropractic philosophy? This phenomenon is a major cause of the low perceived value of chiropractic education and chiropractic care common today.
Fortunately, the CCE of today has moderated its autocratic approach. A genuine effort has been made to emphasize performance based outcomes, and to accommodate a variety of philosophical views. Sadly, the legacy of the past remains, and many students who attended college in the early days of CCE recognition are now teaching. Thus, their deficiencies in traditional chiropractic philosophy are being perpetuated. The opportunity to remedy this situation has presented itself with the new CCE standards. It is now up to the colleges to ensure that the student of today graduates with a strong philosophical base and a keen awareness of the profound potential of chiropractic’s contribution to human health.
Before we feel overly secure with the “new” CCE, we must consider why CCE would alter their standards to accommodate colleges teaching traditional chiropractic. The reason is simple. CCE has made it clear that it will settle for nothing less than a monopoly on chiropractic education. Since the approval of a second chiropractic accrediting agency, the Straight Chiropractic Academic Standards Association (SCASA), CCE has gone to unprecedented lengths to prevent SCASA from being a viable competitor. Having failed, it is now claiming that its new standards will accommodate the philosophical needs of all colleges. But what will happen if SCASA colleges take the bait and join CCE? How long will the new standards last? What will prevent CCE from resuming its former autocratic position?
Insurance
The 1970s saw another event which radically altered the direction of the profession. Chiropractors successfully lobbied for the passage of “insurance equality” laws. These laws mandated payment for chiropractic services by PIP, major medical, and Worker’s Compensation carriers. Limited Medicare coverage was also obtained. Chiropractors were encouraged to bill only for musculoskeletal conditions by a new species — the practice management consultant.
“You want to get paid, don’t you?” was the battle cry. Just bill for sprains, strains, back pain and whiplash injuries. You can make lots of money. If you start talking about infections and visceral disorders, you won’t get paid.” Almost all D.C.s heeded the consultants’ advice. The result? Millions of insurance claim forms providing data suggesting that D.C.s are practitioners specializing in the symptomatic treatment of a narrow range of musculoskeletal disorders.
Carried to its extreme, “insurance driven care” began to emerge. Some practice management consultants encouraged D.C.s to determine the amount an insurance program would pay prior to initiating care. Some D.C.s began to base their care on the insurance coverage of the patient. If a patient’s insurance would pay for 30 visits, the patient would require 30 visits. A 20visit limit meant the patient would get 20 visits. If physician therapy was covered, patients got it. If not, it was omitted. When coverage was exhausted for a given condition, a new diagnosis was generated to “reset” the limits, and the process was repeated.
However, such abuses by a handful of practitioners were not the most pernicious aspect of the plethora of D.C.s developing insurancedependent practices. Virtually all health and accident insurance policies exclude payment for preventive or maintenance care. Furthermore, most policies pay only for the treatment of a specific condition. Thus, the very essence of chiropractic’s unique perspective on health care was compromised — correction of vertebral subluxations to maximize human potential. Insurance doesn’t pay for that, so D.C.s adapted. Some altruistic practitioners compromised themselves by manufacturing musculoskeletal diagnoses so that their patients could “get the care they needed.”
Claims review consultants
Insurance carriers were acutely aware of the fact that a small number of abusers were costing them a fortune. Their response was to initiate claims review procedures to “weed out” abusers. There was little protest from the practitioner community until the claims review process itself became abusive.
Insurers expanded the claims review process, cutting the claims of “middle of the road” practitioners as well as abusers. They determined the amount that they could cut a claim without provoking the practitioner to file suit. The review process became a “let’s make a deal” game where some insurers assumed that virtually all bills would be cut, and practitioners responded by increasing fees to cover anticipated cuts by reviewers.
Soon, insurers found a way to cut costs. By hiring D.C.s to act as “insurance consultants,” large sums of money could be saved. D.C.s who could not make it in practice, recent graduates, retirees, academics seeking to supplement their incomes, and others were all too happy to accuse their colleagues of inappropriate behavior.
This was particularly true if they were protected by a veil of anonymity. Secret “red flag” lists were provided to assist these consultants in justifying their activities. Claim cutting became big business, with some “consultants” making far more money accusing their colleagues of wrongdoing than they ever made providing chiropractic care to willing patients. Often the patient would be sent an explanation of benefits accusing their doctor of administering “unnecessary” treatment or using “experimental” techniques. Such reports have had a devastating effect on doctorpatient relationships.
Research
Another avenue pursued by those who would downgrade chiropractic to a medical specialty treating a narrow array of musculoskeletal pain syndromes is misuse of “research.” CCE was promoted as a means of “upgrading” our colleges. However, it is the opinion of the authors that it was the actions of the CCE in those early days that are responsible for the decline of chiropractic philosophy and technique in many colleges. Similarly, “research” is being touted as another avenue for securing the future of the profession by some of the same “pied pipers” who promoted CCE.
What’s wrong with research? Absolutely nothing. Research projects appropriate to chiropractic are necessary. Research becomes dangerous when allopathic designs are used which suggest that chiropractic is a treatment for pain. It is also an abuse of the research process to selectively disclose research results supporting a given point of view while ignoring contrary evidence, or even denying its existence. Research becomes antiscientific when it fails to recognize a century of clinical tradition and anecdotal results.
Today, a disturbing number of chiropractic college faculty are suggesting to students that the only value “manipulation” has demonstrated is the symptomatic treatment of some forms of low back pain. There are serious problems with this
The most obvious of these is the assumption that “manipulation” and “adjustment” are synonyms. Students are rarely exposed to animal studies suggestive of the influence of spinal subluxations on visceral function. It is also unusual for students to be exposed to anecdotal reports and observational studies suggesting the value of chiropractic care in patients suffering from visceral or infectious conditions.
The role of the nervous system in immunogenesis is similarly downplayed or ignored. Since some of these researchers (such as psychologists), have little or no training in the basic sciences, they tend to emphasize “paper and pencil” instruments instead of anatomical and physiological measurements for patient evaluation.
Furthermore, the studies cited by these “pied pipers” in support of their “back pain” position have significant shortcomings. What criteria are used to determine clinical need for the manipulation? Are these techniques reliable? How is the manipulation applied? The authors are unaware of any studies where reliable and objective criteria were used to determine the need for “manipulation,” or to verify the success of the reduction. Are the “manipulations” administered true chiropractic adjustments, where listings are determined by a clearly defined protocol, and adjustments consistently and specifically applied?
This brings us to yet another problem. These same researchers are actively disparaging the very tools necessary to objectively evaluate various components of the vertebral subluxation complex. Xray spinography is dismissed as “an abuse of radiation.” Students are not exposed to studies which refute this viewpoint. Similarly, videofluoroscopy is dismissed with the claim that normal has never been defined. Students are not exposed to the plethora of refereed literature supporting the use of the procedure. Surface EMG is dismissed as “investigational” despite its distinguished track record in the scientific literature.
Not content to limit their poison to students, some of these researchers have offered their “opinions” to insurance companies, suggesting that chiropractors who use objective outcome measures for subluxationrelated phenomenon are over utilizing and engaging in human experimentation! Of course, such “opinions” are generally not supported by any scientific literature.
A curious double standard has become evident. For example, in the oft praised RAND Corporation study, “Case reports were excluded, except to document complications.” [3] In other words, case reports describing the benefits of chiropractic care were ignored, while reports of complications were included. They’ll accept the negative, but not the positive. This is science? Certainly not!
Examining boards
Members of state examining boards are generally political appointees selected by the governor. Remember, many of these folks fought hard to ensure that only graduates of CCE colleges could sit for exams. More than one “18month wonder” possessing less than two years of postsecondary education has lobbied with vigor for mandating a fouryear licensure.
Many board members, while experienced practitioners, are not familiar with contemporary technologies for detecting and characterizing the vertebral subluxation. The authors seriously question how many of these people could pass their own exams without an answer key.
While some boards have sought to attract new practitioners to their states, they seem to be the exception rather than the rule. Some boards seem more concerned with limiting competition and pandering to insurance interests than maintaining quality assurance.
The insurance industry has found willing allies in many examining boards. While pursuing a civil suit can be costly and time consuming, a complaint to a state board can be made for the cost of a postage stamp. The investigative costs, attorney fees, etc., required to process a complaint from an insurance company are borne by the taxpayers. Thus, insurance companies can use the resources of the state for the selfserving purpose of minimizing cash outflow. The chiropractor who falls prey to this scheme must bear the emotional and financial cost of presenting a defense.
The consensus con
The latest strategy of the chiropractoid “pied pipers” is the development of practice guidelines. To promulgate such guidelines, they convened the “Mercy Center Conference” and promoted it as adequately representing all factions within the chiropractic profession. Of the 35 participants, the vast majority represented the “disease treatment” paradigm. The ICA had only a few voting participants. The SCASA faction had but one. With such an overwhelming imbalance, how could one hope to produce a document which adequately represented the interests of subluxationbased chiropractic?
Why wasn’t a single ICA radiologist on the panel, when the ACA had many? Why weren’t the research directors of the two largest chiropractic colleges in the world present? Why wasn’t the ICA researcher of the year invited to participate, when the ACA research arm was more than adequately represented? Why did the ICA and SCASA even agree to participate given such an overwhelming imbalance of votes?
The structure of the conference was designed to suppress dissent. Participants were carefully selected. Observers were prohibited from attending committee meetings, even in a passive, nonspeaking capacity. What did they have to hide?
Recorders were forbidden. Why? Definitions and reviews of literature were not even open to debate. Only recommendations were debated and voted upon, and time was limited. Why? Only official observers and participants were allowed to attend. Why not any D.C.? And why not let any D.C. participate in free and open debate? The framers of this debacle may claim the reasons were time and space constraints. But with issues this important, couldn’t these concerns have been overcome?
The highly biased, incomplete reviews of literature concerning subluxationbased instrumentation, such as surface EMG and thermocouple instruments, could not be challenged. Yet many participants relied on these reviews, and the biases of their authors, to form decisions.
The most ridiculous part of the conference dealt with complications. Participants voted on the probability of complications arising from given conditions. How can the incidence of adverse reactions be voted upon? Either you have the data or you don’t! Guessing at numbers based upon conjecture and an occasional case report is absurd. The very people who discount favorable case reports seemed more than willing to draw sweeping conclusions from negative case reports.
The profession has been sold yet another “bill of goods” by a group of individuals who expect their document to be accepted without question. There are no provisions for revising it. The field is expected to embrace it without question. If the profession does accept the jurisdiction of this document, subluxationbased chiropractic will suffer.
Coincidence or conspiracy?
Are these events mere coincidence, or is there an organized conspiracy to make chiropractic a subset of allopathic medicine? This the reader must decide.
Sociologist Walter Wardwell in his chapter, “Present and future role of the chiropractor” in Haldeman’s “Modern Developments in the Principles and Practice of Chiropractic,” argues for chiropractors becoming “limited medical practitioners.” He mentions such professions as dentistry, optometry, podiatry, and psychology, observing that “they do not challenge medicine’s basic theories of disease and therapy.” Why should chiropractic follow suit? Wardwell lists the following:
1. Chiropractors in fact devote most of their time to the alleviation of neuromusculoskeletal symptoms.
2. These conditions are the kinds that the public believes that chiropractors can treat best.
3. It is for such conditions that physicians and other providers are most likely to refer patients to chiropractors.
4. Third party payers are most willing to reimburse chiropractors for treating such conditions.
5. There is a more obvious and direct relationship between chiropractic adjustments and such conditions.
6. If a chiropractor is especially cautious or concerned about his image, it is no doubt safer for him to restrict his practice to neuromusculoskeletal conditions than to attempt to treat systemic conditions or those involving internal organs. [4]
In short, if we sell out our principle, and reinforce the inaccurate and limited perspective we have allowed to develop in the minds of the public, it will be easier to milk the insurance cow!
What price would we pay for taking such a course? Rather than consider the loss to the chiropractor, consider the loss to humanity.
How many infants will die needlessly from SIDS because of atlantooccipital subluxations? How many children will develop chronic diseases because of subluxations? How many unnecessary antibiotics will be prescribed, and what will be the ecological impact of such indiscriminate therapy? How many surgeries will be performed that could be avoided? How many families will remain childless because a parent has a subluxation preventing conception? How many people will be unable to fully express their genetic potential because of subluxation? And how will this interference affect them on a psychological and emotional level? How will it affect their relationships with others? How will it affect society as a whole?
Principles or politics?
The fundamental issues are simple. Are we a profession with a clearly defined mission, or are we a profession simply seeking some niche which offers access to a slice of the health care pie? Are we driven by principles or politics?
In discussing the diversity of individuals in the profession, B.J. Palmer stated, “When it comes to Chiropractic we are agreed upon Innate, subluxation, and adjustment. Chiropractic overshadows dissolution and procedures union.” [5] He was aware that unity would occur when chiropractors were driven by principles.
He was equally aware of the other faction. B.J. explained, “They had no one agreed understanding on philosophy, science, and art. They had one dollar god before them, regardless of what damage was done the sick who were searching health. This heterogeneous mass had no goal. There was no fundamental upon which they could join hands. Posterity was measured in terms of dollars to them today. They agree upon two things: money and disgrace!” [5]
The solutions to our situation are simple. We must realize that our hardwon political victories were achieved because our forebears were driven by a desire to bring chiropractic to the people. Despite their political differences, they were one in their zeal to get chiropractic’s unique contribution to humanity as widely disseminated as possible. They may have differed on scope of practice issues, but were united by a common denominator — correction of vertebral subluxations.
They also embraced a vision of chiropractic care influencing the entire body. They did not confine their services to patients with musculoskeletal problems. Differences between the allopathic approach and the chiropractic approach to health problems were accentuated. Yes, our predecessors knew that chiropractic offered something medicine did not — a separate, distinct, nonduplicating health service.
Are you driven by principles or politics?
References
1. Letter from David A. Kendig, M.D., Deputy Director, Bureau of Health Manpower, DHEW, to Reginald R. Gold, D.C., Ph.C., Jan. 30, 1976.
2. Letter from Orval Hidde, D.C. (CCE Commission Chairman) to Joseph Mazzarrelli, D.C. (ICA President), July 11, 1977.
3. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Book RH: “The appropriateness of spinal manipulation for lowback pain. Project overview and literature review.” Santa Monica, CA RAND. 1991. R4025/1CCR/FCER. Page 3.
4. Wardwell WI: “Present and future role of the chiropractor.” In Haldeman S (ed): “Modern Developments in the Principles and Practice of Chiropractic.” AppletonCenturyCrofts, Norwalk, CT 1980. Page 38.
5. Palmer BJ: Answers. The Palmer School of Chiropractic. Davenport, IA. Vol. XXVIII. 1952. Pages 711713.
