As chiropractic moves forward with its bid for the conservative spine care market[2, 3], it, like all professions does not function as a single unit. Despite the importance of perceived unity, professions are often challenged by their strata[31–34]. The management of dissident views and related internal and external constraints will need to be considered as health care evolves toward more team-based interprofessional care.
Although perceived divisions within the chiropractic profession have been well described[18, 19], current models suggest that there are not two, but six strata within chiropractic – only one of which is clearly dissident from the majority.
Historical views of competing factions within the chiropractic discipline no longer apply. The notion of two basic groups: “straights” and “mixers” through the early half of the 20th century appears to have changed. The majority of practitioners historically were thought of as “straights”, perceived the subluxation as the cause of disease and its remedy to be manipulation/adjustment. This dominant faction was schooled through a single institution that boasted an enrollment of 505 students as early as 1910. Interestingly, the evolution of subluxation as an impediment to health appears to have been a medicolegal maneuver to distinguish chiropractic from medicine and to defend against a charge of practicing medicine without a license. The defence took note of the philosophical perspective of Langworthy on the supremacy of nerves in modulating health. Together, the medicolegal defence linked with this philosophy to proffer subluxation as an obstruction to human health (p. 66–67).
The data in this investigation suggest that only 18.8% of chiropractors in Canada today define themselves in accordance with Langworthy’s original premise. This figure is consistent with McDonald’s data in the United States from 2003, whereby a survey of 647 chiropractors suggested that 19.3% of practitioners could be identified in this way relative to their scope of practice. McGregor-Triano found 17.2% of 64 chiropractors from around the world, responding to a survey at a chiropractic conference, could be identified as belonging to the subgroup of practitioners for whom subluxation was considered an obstruction to human health. Finally Palmer, evaluating attitudes among chiropractors in South Africa, found that 17.9% of 56 practitioners in the great Durban area responding to his survey, considered themselves to be “straight” practitioners, as defined by removing subluxation to facilitate healing (p. 71).
Statistical modeling suggests that affiliation with dissident group membership can be predicted by attitudes and behaviours likely to be in contrast to scientifically-based practice. Logistic regression of the survey data supported the notion that a perceived scope of utilization for conditions beyond evidence-based treatment choices, a negative attitude toward vaccination and self-reported use of x-rays outside of currently accepted guidelines were significant predictors of unorthodox versus orthodox perspectives. All three attitudes were associated with an increased odds of holding an unorthodox view.
The work of Busse et al. indicates that many orthopaedic surgeons in North America consider the diversity within the chiropractic profession as an obstacle to interprofessional care, citing specifically, issues such as a scope of practice associated with non-musculoskeletal conditions. One purpose for our investigation was to extend the discourse around chiropractic’s relationship to medicine. During the early years of chiropractic, at the Palmer school and with Langworthy’s efforts to distinguish the profession, a majority of chiropractors held the belief that the lesion treated by chiropractors (subluxation) was a means of caring for the health and well-being of each individual in the population. Today it is clear that this view has only been retained by a minority of the profession. No historical data exist to track Langworthy’s paradigm of subluxation through the last 100 years. At the time of Langworthy’s book, little was understood in health care by all professions. Medicine was unorganized and its rival factions were well documented. No single health care profession had yet achieved dominance. Treatments that were truly efficacious were rare and medical practitioners held the key to few cures. With the advent of the Flexner report and the discovery of antibiotics, medicine shifted strongly towards a science-based focus, from which knowledge grew exponentially.
From the data in our investigation, like the growth in medicine, it appears that the paradigm for the chiropractic profession has since shifted as well. Evidence of marginalization by the chiropractic profession of its unorthodox sect is indicated by the relative number of publications in its mainstream journal compared to the number associated with its dissident counterpart. From 1978 through 2004 for example, there were 1,394 abstracts available in the peer-reviewed and indexed journal most strongly affiliated with the chiropractic profession. For the same years there were only 55 abstracts associated with the periodical expressing a predominantly non-evidence-based view.
Despite this, orthopaedic surgeons’ views about chiropractic remain largely focused on chiropractic dissidents. It may be therefore, that the unusual focus remains as a result of media attention on and associated with this unorthodox group. Media influences and direct access to the public, as indicated by Schuklenk can have a dramatic influence in health care, and perhaps as well in relationships between professions. In addition, the relationship between medicine and chiropractic may be affected by social phenomena such as the “minimal group effect”, whereby even relatively minor distinctions between groups can result in prejudice. LaBianca, Brass and Gray suggest an alternative social phenomenon in intergroup conflict. Their research suggests that intragroup strata may negatively impact perceptions of intergroup relationships. Thus diversity within both medicine and chiropractic may be challenging the relationship between them.
Regardless of the cause, interest in interprofessional collaboration as a means of effectively managing complexity and cost in today’s health care environment has increased[40–42]. Meeting the needs of the public, increasingly requires multiple knowledge sets and consistent performance. At the dawn of the 21st century organizations such as the Institute of Medicine noted that delivery of health care was “cumbersome” (p.1), failing to “build on the strengths of all health care professionals” (p. 2), and as one of its six challenges, called for the need to develop effective teams. As the complexity of health care continues to grow, and greater need is exhibited for team approaches, the efficient and effective distribution of health care associated with musculoskeletal pain will require a willingness of both groups to acknowledge their respective value while learning to build on identifiable constructs held by both.
Good evidence exists for the effective use of manual treatment methods and in particular those associated with the high velocity low amplitude manipulation commonly conducted by chiropractors[44, 45]. As such, strong cooperative relationships between chiropractors and other members of the health care team concerned with neuromusculoskeletal care, such as orthopaedic surgeons, should be expected to advantage patient care.
Management toward a collaborative focus however, will require a clearer understanding of the strata that exist within both professions, and the common goals that exist between them. In addition, social phenomena related to inter and intra group behavior may need to be considered in the creation and maintenance of health care teams in the future. Further study is suggested to investigate potential causal mechanisms associated with the continued challenges faced by chiropractic and medicine, during this era of collaborative care.
As with any investigation, this study has limitations. First, although the response rate was good at 68%, it remains unclear what practice perspectives and behaviours are associated with non-participants. Also, although the sample was randomly selected and stratified according to the number of licensed practitioners in each province, the sample represented only approximately 12 percent of practitioners from each province. As always, there is the possibility that despite the randomization scheme, a unique sample was selected, and generalizability is a possible concern. Both concerns seem unlikely, however, given the consistency of the number of dissidents calculated in other investigations of chiropractic[3, 22, 36].