A Proposal Regarding the Identity of Chiropractic:
Embrace the Centrality of the SpineThis section is compiled by John Wiens, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Journal of Chiropractic Humanities 2005; 12 (1): 8–15
Bram B. Briggance, PhD
Program Director,
UCSF Center for the Health Professions,
University of California,
San Francisco,
3333 California Street, Suite 410,
San Francisco, CA 94118.
Objective: To offer the following proposition: the spine is inextricable from and absolutely essential to the identity of the chiropractic profession.
Discussion: In order to determine the identity of the chiropractic profession two separate approaches are made: first, the question is examined philosophically; the profession is defined by determining its essence; what it is, what it is not, and what it is for. Second, the question is examined pragmatically, by determining chiropractic’s role in people’s lives; how it is defined by the public and what chiropractic practitioners actually do.
Conclusions: Philosophically, chiropractic’s essence, boundaries, and purpose are oriented by the spine; practically speaking, the spine is where doctors of chiropractic apply the vast majority of their work. The author suggests that embracing the spine as the center of chiropractic identity does not limit the profession but, rather gives the public and the profession a common referent to define chiropractic’s function and value.
Key Indexing Terms: Chiropractic; Spine; Identity
From the FULL TEXT Article:
INTRODUCTION
In February 2004 I was invited to serve as a lay representative on a task force to lead the World Federation of Chiropractic’s (WFC) Consultation on the Identity of the Chiropractic Profession. The fundamental question at hand was “What is the identity of chiropractic?” It became increasingly clear that the set of questions with which our group was wrestling was philosophical in nature (Figure 1).
A good deal of my professional work concerns the fundamental relation of a profession’s identity to its current and future success. In order to succeed in an environment as dynamic and volatile as health care, it is critical to distinguish between those aspects of a given profession that are vital to it and those aspects that are inessential, and often create costly distractions. Unless one has a clear understanding of who he or she is and of what needs to be achieved, it is impossible to make even simple strategic decisions.
The following discussion is a modest attempt to contribute to the serious and earnest discussions underway within the chiropractic profession about the nature of its identity. As a health expert, a chiropractic outsider, a trained philosopher, and as someone who has personally benefited from chiropractic care, I offer the following proposition: the spine is inextricable from and absolutely essential to the identity of the chiropractic profession.
In order to determine the true identity of a profession there are two general approaches. The first way is to examine it philosophically. This means trying to define the profession by determining its essence; what it is, what it is not, what it is for. The second approach involves determining its everyday role in people’s lives; determining how it is defined by the public and what its practitioners actually do. Both of these approaches support the proposition that the spine is essential to the identity of the chiropractic profession.
DISCUSSION
A Philosophical Approach to the Identity of Chiropractic
The question of identity, what makes any given thing the thing that it is, is a metaphysical question. Traditional metaphysics is the area of western philosophy concerned with the structure, order, and causes of all things that exist. This field was largely shaped by a collection of writings by Aristotle known as Metaphysics. For our purposes, examining the question of the identity of the chiropractic profession, I suggest that it may be helpful to utilize three basic approaches used by Aristotle and others to determine what something is.
The first approach is to try to identify the eidos, or essence of something. The eidos is that set of characteristics that make a thing the thing that it is rather than something else. For example, the eidos of a triangle would be that it has three sides, three corners, and 180 interior degrees, and so forth.
A second way to determine something’s identity is to look at how something fits into the order of things. To do this we determine its public definition or horizmos. The word horizmos shares its root (horos) with the word horizon. Just as the horizon is the boundary of all that can be seen, horizmos is the boundary of a particular category used to sort things. Examples of definitions derived by this approach are the traditional classification of plants and animals by their behaviors and characteristics. These types of definitions do not necessarily capture the true essence of the thing they define, but rather identify a set of characteristics that distinguish that thing from all other types of things. The horizmos for a swan, for example, may not give an exact definition of “swanness,” but rather may list its unique combination of attributes (eg, a bird with a long neck, white feathers, etc.)
The last avenue I propose we examine to explore philosophically the identity of the chiropractic profession is to look at its telos.
A thing’s telos (for Aristotle inseparable from its eidos) is its purpose or function. Determining what a particular thing does or strives to do goes a long way toward understanding what it is. If a thing is designed to stop a door from swinging shut we might say that what it is, in essence, is a “doorstop.” The telos of a profession is the end toward which it strives. The telos of a gardener, for example, might be to maintain a healthy and attractive garden.
For each of these ways of determining a thing’s identity it is crucial that the definition reached is neither too narrow nor too broad. Using the examples above, we can see that eidetically (according to a thing’s eidos) a “triangle” is neither “a geometric shape” nor “a figure with three equal sides.” Both of these definitions fail to capture the essence of a triangle. Similarly, a proper horizmos for “swan” is not simply “a white bird” or the “title character from The Ugly Duckling” but rather is the exact classification that applies to all swans and nothing else. Teleologically, the defining function of a “gardener,” for example, cannot be “to care for plants.” This definition is too broad in the sense that it could be said of other professions, and too narrow in the sense that it does not capture all that a gardener must do. Using these three philosophical approaches let us examine the identity of chiropractic.
The Eidos of Chiropractic
What, in essence, is chiropractic? Because the profession does not share the theoretical framework that is the basis of allopathic medicine, nursing, and the rest of the other licensed allied health professions, it would be a mistake to determine its precise nature using a pathological model. Chiropractic is predicated on the belief that health is largely determined by the extent to which one’s nervous system is functioning properly. The chiropractic approach holds that a body’s nervous system, under proper conditions, has sustaining and recuperative powers to preserve itself in a state of health. Chiropractic’s clinical concern is rooted in determining the ways in which a patient’s nervous system is being hindered in its normal functions. Chiropractic’s approach is aimed at the elimination or sufficient amelioration of those hindrances in order to restore the patient to a state of selfsustaining health. [1] I argue, then, that a workable eidetic definition of “chiropractic” would be: the health profession that is primarily concerned with the amelioration or elimination of the abnormal physiology that creates the potential for a diseased state.
How does this definition of the profession match my proposed claim that the spine is essential to and inextricable from chiropractic’s identity? The primary locus of abnormal physiology that chiropractors treat is the spine. This fact makes the manipulation and adjustment of the spinal column absolutely essential to health and the chief business of chiropractic. Given this, we can conclude that, at least eidically, the spine is essential to the identity of chiropractic.
The Horizmos of Chiropractic
Creating a definition of the chiropractic profession that distinguishes it from all other professions is a tricky task, but it is the kind of task people do out of necessity all the time. Trying to determine the boundaries of a definition is usually not an exact science. Common definitions are rarely complete; the characteristics they emphasize may serve some purposes very well but may fail in other important respects. A quick look at some of the countless attempts to define the chiropractic profession reveals some of this complexity.
The etymology of “chiropractic,” the name chosen by the profession is chiropraktikos, which means “effective treatment by hand” or “done by hand”. [2, 3] This label captures an important and distinguishing aspect of the profession. However, we can imagine it being chosen to identify any number of occupations, such as pottery, massage therapy, or bread making just as appropriately.
The language in the legal scope of practice for the chiropractic profession in the state of California, USA, for example, states that chiropractors may perform, [4] “…all necessary …measures incident to the care of the body…in the course of chiropractic manipulations and/or adjustments.” This legal language affirms chiropractic as a health profession concerned with care of the body. It also implies professional autonomy (and fiduciary responsibility) by granting the profession license to perform “all necessary measures” in its practice. By using the phrase “in the course of chiropractic manipulation” it also limits the chiropractor’s application of “all necessary measures” in caring for “the body”. Unless one also knows these limits, however, this passage is not particularly helpful in clarifying what chiropractors do.
The National Board of Chiropractic Examiners (NBCE) writes, [1] “Chiropractic is a natural, conservative, drug-free and nonsurgical form of health care.” This description goes a long way in narrowing the field of chiropractic by defining it against what it is not; namely, it states that chiropractic is not unnatural, radical, pharmacological, nor surgical. This description alone, however, would not necessarily exclude other health providers such as physical therapists, dieticians, and acupuncturists. The same is true of any number of descriptors such as “primary care,” “primary contact,” “holistic,” and others, all of which could be applied to chiropractors and non-chiropractors alike.
The key to determining the proper boundaries of a definition of chiropractic is to find ones that allow the inclusion of all of those we would consider chiropractors and exclude anyone who is not one. To resort to simply using educational training or licensure status only sidesteps the question we are trying to answer. I suggest that the natural, practical boundaries that determine the chiropractic field are logically tethered to the elimination of any abnormal physiological alignment via chiropractic adjustment. Specifically, I submit that the defining characteristic of chiropractic is its unique, specialized approach to improving the physiological functions, and thereby the health, its patients.
Most are aware of the impassioned internecine battles within the chiropractic profession about the cost of focusing on this fundamental aspect of clinical care to the exclusion of others. However, it seems that many of the worries about such a definition reducing chiropractic to a mere “technique” or weakening its claim as a “primary care” profession are unfounded. It is indisputable that doctors of chiropractic provide a host of non-adjustive, meaningful health services to their patients. I also accept that the holistic approach to health and the attention to the psychosocial aspects of their patients’ lives are integral to providing effective chiropractic care. However, these aspects are not distinguishing characteristics of the profession. One valuable service provided by many chiropractors is nutritional counseling. While it may be appropriate for a chiropractor to do so, it would seem that nutritional counseling is not a true “chiropractic” service. Could not the nutritional counseling provided by any given chiropractor come from another source such as a physician, nurse, nutritionist, or fitness trainer? Would we say that a school nurse is practicing chiropractic without a license if he or she recommends reducing the amount of processed sugar in a student’s diet? It seems reasonable to conclude, rather, that the responsibility of promoting health through proper nutrition is a responsibility chiropractors share with non-chiropractic members of a broader category, perhaps appropriately labeled “health professionals.”
Similarly, the professional culture of chiropractic prides itself on its attempt to treat the whole patient. One might argue that chiropractic’s emphasis of this need, and perhaps its relative success at executing it, are unique, but they should not be. As someone who works to improve the effectiveness of practitioners across the health spectrum, such an approach is integral to good clinical care generally, not chiropractic care alone. A decision by chiropractic to relinquish sole ownership of a “total person” model of care would do little to threaten the profession, but it might present a valuable opportunity to establish itself as a true leader in this regard among all health professions. Likewise, that chiropractic treatment is designed to benefit the entire body makes it no more inherently holistic than, say, cardiology. It only means that chiropractic has cultivated a broader vision, one other professions might do well to emulate.
If we accept that non-adjustive clinical services are not strictly “chiropractic care” and that taking a more holistic approach to health care provision is a mark of excellence for health care providers rather than a marker for any particular profession, then what is unique to chiropractic is its clinical approach to health. The horizon of the chiropractic profession, its defining boundary, is the amelioration of any deleterious physiological alignment via chiropractic adjustments.
The Telos of Chiropractic
A teleological definition of chiropractic is one that determines what it is according to its function or purpose. As with our attempt to pin down the chiropractic profession’s boundaries, the definition can neither be too broad nor too narrow; it must distinguish the chiropractic profession from all others by identifying what is unique to it. To say that a chiropractor’s function is to “maintain the health of those they serve,” for example, could be applied to any number of health professionals (as well as crossing guards and fire marshals) and is therefore too broad. Likewise, defining chiropractic as the discrete goal of any particular action or set of actions performed during chiropractic treatment is too narrow.
To properly define a profession this way one must follow a kind of “chain of purpose” until he or she arrives at the most general defining purpose. For example, one might say that the goal of a particular manipulation of the lower spine is to restore its proper alignment. However, we must continue by asking, “Why is that alignment desirable?” Perhaps it is to improve the function of the thoracolumbar nerves, which may be done to improve the function of the kidneys, which may be jeopardizing the health and comfort of the patient, and so on. I would suggest a reasonable approach, especially given our previous discussion, is to posit that the telos of chiropractic is improvement and maintenance of the health of those they serve through the chiropractic adjustment. Such a definition would apply to all chiropractors and no one else, and could provide the most general appropriate teleological understanding of the substance and purpose of any given clinical chiropractic intervention. Again, because it is the primary locus of chiropractic adjustment, the spinal column and chiropractor’s identity as defined by its function is inextricably linked.
To provide a thorough theoretical, and in this case ontological, examination of the chiropractic profession is a major undertaking. I do not claim that I have accomplished anything like that here. But, if the observations made here are generally on target, then arguing that chiropractic’s identity can somehow be separated from its relation to the spinal column is a tall order. Specifically, such an argument would have to do at least one of the following: 1) provide a clinical paradigm for the profession that does not rely on the amelioration of abnormal physiology via adjustment, the theoretical model that has shaped its history and frames it clinical education today; 2) provide a clinical model for treating such abnormal physiology in which the spinal column plays no role or only a very minor role, and that could be appropriately said to be a “chiropractic” model. Such a theoretical reframing of the profession would be truly revolutionary, and perhaps it is an endeavor worth attempting. In the meantime, however, I see no clear way of separating the spine from the essence of the profession, from its logical boundaries, and from its clearest purpose.
A Practical Approach to the Identity of Chiropractic
Many readers may find the philosophical discussion in the previous paragraphs either unpersuasive or inessential to the question of chiropractic’s “real” identity. I propose that the conclusions about the inextricability of the spinal column from the identity of chiropractic are just as valid when evaluated with regard to both what chiropractors actually do, and by what the general public perceives that they do. Let us look briefly at each of these ways of determining identity.
Chiropractic Identity as “What Chiropractors Actually Do”
National survey data show that doctors of chiropractic estimate that their work time is fairly evenly divided between direct patient care and all other practice responsibilities. Non-patient care activities performed by doctors of chiropractic include patient education, documentation, research, business and marketing responsibilities. [1] These non-clinical responsibilities are nonchiropractic ones and do not aid in properly defining the profession for the following two reasons.
First, the responsibilities of managing clients, keeping records, though important, are not unique to chiropractic, and therefore not particularly helpful in pinning down what a chiropractor is. Second, just because a chiropractor often does these things does not mean that he or she would be “less” of a chiropractor if they were not done or done by others. A plumber, for example, may have to spend a great deal of time coordinating appointments, driving to job sites, etc. While we might say that these are things a plumber often must do, we would not say he is “plumbing” when he or she performing them. Similarly, some of the duties chiropractors perform in this regard are because almost 19 in 20 chiropractors work in private office settings, with twothirds of those in solo practices. [1] These facts pertain to the work that chiropractors do, but not to what one does when practicing chiropractic. For that we must examine what chiropractors do clinically.
Multiple survey data confirm that for almost all doctors of chiropractic, spinal manipulation pertaining to subluxation/joint dysfunction is the most common and fundamental treatment performed. [1, 5] While surveyed chiropractors report seeing a wide range of conditions, including allergies, high blood pressure, obesity, asthma, diabetes, and infections, these were reported as being treated by them only once or twice a month. [1, 5] One study, which utilized patient records, concluded that no nonmusculoskeletal condition constituted more than 1% of patients’ symptoms. [1, 5] I have seen no evidence that these and similar research findings are grossly inaccurate reflections of how most doctors of chiropractic spend their clinical time. If it is reasonable to say that the professional identity of a clinical profession should largely be defined by the services it most often performs, then, practically speaking, it seems clear that spinal manipulation is essentially what chiropractors do, and thus how they can best be identified.
Chiropractic Identity as “What Chiropractors are Known For”
In a recent exchange, a president of a marketing firm that has done extensive work with the chiropractic profession stated, “There’s no question as to the centrality of the back/spine to the public's perception of chiropractic.” There is a large and increasing body of evidence to support this claim. However, even without such data, the evidence of the connection in the public eye between the back and spine and the profession is so ubiquitous that it is almost understood without saying. One only has to look at chiropractic office signs, advertising materials, websites and so on, to see that practitioners already accept this fact and continuously reinforce it in their public interactions. This connection is also evidenced in the everyday manner in which the profession and its services are discussed among most people.
Such evidence demonstrate what the public’s perception is, not whether or not it is accurate. Many professions, nursing for example, suffer from a serious misunderstanding by the public about what its practitioners actually do. While woefully simple and incomplete, I argue that the public association of chiropractic with the back/spine is essentially correct, and far more accurate than it is for many health professions.
Attempting to uproot such a well-ensconced professional image is not only extremely difficult (perhaps impossible), in the case of chiropractic it also may prove to be dangerous as well. In a recent survey chiropractors reported, on average, that no profession referred patients to them with a frequency of more than “one or two per month,” and most fell well below an average of “one or two per year,” or did not refer at all. Another study concluded that only 50-60% of medical providers refer patients for chiropractic care. [5] A profession that relies so heavily upon the public voluntarily seeking its services should be very cautious about razing the bridges the public uses to reach it.
CONCLUSION
In this paper, I have tried to demonstrate that the centrality of the spine to the identity of chiropractic is absolutely clear: philosophically, chiropractic’s essence, boundaries, and purpose are all oriented by the spinal column; practically speaking, the spine is where chiropractors do the vast majority of their work; and also that the public already has a strong impression of what chiropractors do, and that this impression is mostly on target. Simply put, chiropractors own the “market” on the spine and focus most of their effort there. I suggest that embracing the spine as the center of chiropractic identity does not limit the profession but, rather, simply gives the public and the profession a common referent to define chiropractic’s function and value. I also believe that to dismiss such an obvious and workable marriage of public and professional identity could be very detrimental to the health of the profession.
In Cat’s Cradle Kurt Vonnegut writes, “Any scientist who cannot explain to an 8-year-old what he is doing is a charlatan.” Chiropractors have a way to explain to an 8-year-old what they do, “The nerves in your spine connect to every part of your body. To remain healthy, it is extremely important that all the parts of your spine are working together properly. Chiropractors make sure that they are.” It would seem a shame not to take advantage of this elegant and accurate explanation.
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Greeley (CO): National Board of Chiropractic Examiners, 2000.American Chiropractic Association.
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In: Briggance BB, editor.
San Francisco, CA: unpublished; 2003.California Board of Chiropractic Examiners.
Laws and Regulations Relating to the Practice of Chiropractic.
Sacramento: California Board of Chiropractic Examiners; 2003. p. 4.Cherkin DC, Mootz RD, eds.
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