Caught in the Crosshairs:
Identity and Cultural Authority Within ChiropracticThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Social Science & Medicine 2011 (Jun); 72 (11): 1826–1837 ~ FULL TEXT
Yvonne Villanueva-Russell, Ph.D
Dept. of Sociology,
Texas A&M University-Commerce,
Sociology & Criminal Justice,
TX 75429-3011, USA.
In this paper the discourse over identity and cultural authority within the profession of chiropractic in the United States has been analyzed using critical discourse analysis. As the profession struggles to construct one singular image, versions of self must be internally debated and also shaped in consideration of larger, external forces. The dilemma of remaining tied to a marginal professional status must be balanced against considerations of integration. Written texts from chiropractic journals and newspapers are analyzed in a multidimensional approach that considers the rhetorical devices and thematic issues of identity construction; the representation of various voices within the discourse (both heard and unheard); and the extent to which external pressures affect the projection of cultural authority for the profession. A heterogeneous discourse characterized by conflict was found, with discrepancies between everyday chiropractors in actual practice versus academic chiropractors and leaders particularly over the idea, practice and significance of science for the profession.
Key Indexing Terms USA, Chiropractic, Identity, Professionalization, Cultural authority, Critical discourse analysis, Review
From the FULL TEXT Article:
Introduction
Professional identity and cultural authority are two concepts that have appeared in the chiropractic literature with increasing frequency in the past decade. In 2002, Meeker and Haldeman published “Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine” which evoked a clarion cry for intraprofessional introspection. Commenting on the success of having achieved professional status in the United States, Meeker and Haldeman argued that chiropractic was still “trapped” with an unsatisfactory marginal position — part of mainstream medicine but not fully accepted or participating in it.Chiropractic still maintains some vestiges of an alternative health care profession in image, attitude and practice. The profession has not resolved questions of professional and social identity and it has not come to a consensus on the implications of integration into mainstream health care delivery systems and processes. In today’s dynamic health care milieu, chiropractic stands at the crossroads of mainstream and alternative medicine. (p. 223)
Professions have been well studied for several decades in the sociological literature. Andrew Abbott’s (1988) contribution has been to focus on the cognitive knowledge claims of expertise that are constructed to enable professions to co-exist and compete with one another in a larger system where they may be accepted or rejected. This research will examine statements made by US chiropractors found in printed sources (i.e., journals, newspapers) to reveal how internal identity claims are formulated as well as how an outward projection of cultural authority (the ability to be unquestioningly believed (Starr, 1984, p. 13)) is presented in a changing health care environment.
In health care, orthodox medicine has “professional dominance” and possesses the largest jurisdiction (c.f., Freidson, 1970; Pescosolido, 2006; Willis, 2006), although much discussion of the decline of this hegemonic power has also occurred in the literature (c.f., Haug & Lavin, 1983; Wolinsky, 1993). Complementary and Alternative Medicine (CAM) has established itself as a “marginal profession” in relation to this framework.Wardwell (1994) defined marginal as an occupation that operated with autonomy from medicine and rejected the medical definitions of illness and treatment held by the mainstream (p. 1063). In their original formulations, chiropractic, acupuncture, and homeopathy all existed as paradigms and theories of disease that stood outside of orthodox medicine and were largely incommensurate to the medical model.
In the US, chiropractic is unique from other CAM specialties because it has fully achieved all aspects of professional status (it is recognized by state licensure, has standardized and accredited education, and serves as a primary contact doctor) but has only restricted access to the institutional aspects of medicine (lacks university affiliation and therefore lacks major research funding, has only limited access to hospitals, and receives limited insurance reimbursement). Wardwell advocated for chiropractic to become a “limited profession” whereby the scope of practice would be restrained to a more narrow range while remaining autonomous and free from the need for referral or supervision from orthodox medicine (1994, pp. 1062e1063). In recent years there has been a heightened push within chiropractic to do just what Wardwell (1996) had urged a decade before: transform from marginal to limited profession. This has triggered heated debate amongst chiropractors. This debate forms a discourse: its content, power struggles and functions are the focus of this research.
Review of literature
Professional identity
Professions must profess something. This is a reflection of the work they do, but also their inner-identity which defines who they are. In the case of CAM, this often means emulating the structural characteristics established by orthodox medicine: obtaining licensure, educational accreditation, etc. Welsh, Kelner, Wellman, and Boon (2004) note that many CAM professions “run the risk of mistaking the allopathic medical model for the paradigm of professionalization” (p. 237).
US chiropractors have achieved all professional attributes, yet the professional self continues to evolve and adapt. Rather than assume professions are homogenous and cohesive, Bucher and Strauss (1961) note that various “segments” often occur within a profession, leading to internal conflicts and power struggles. The micropolitics of segments may lead to “boundary work,” (Gieryn, 1983) a process where groups may try to achieve demarcation between themselves and rivals. Welsh et al. (2004) studied three different CAM groups in Canada to investigate the strategies employed to gain state regulation, a key attribute of professionalization. In the case of Traditional Chinese Medicine (TCM)/ acupuncturists, one segment that regarded themselves as traditional and pure faced conflict with the more scientific Western, allopathically-trained practitioners that viewed Chinese Medicine as an adjunct to their (largely biomedical) armamentarium. To demarcate the latter segment from the former, science was used as a rhetorical tool to elevate their techniques and educational rigor as superior. The use of rhetoric is a common way to formulate professional identity, particularly during times of crisis, internal skirmishes or even interprofessional conflicts with competitors. Science is only one grounds of professional struggle, however. Warnock (2005) found an agonistic or war-like use of rhetoric to conjure up loyalty and cohesion when optometrists sought to expand for greater autonomy against their interprofessional rival, the ophthalmologists. Allen (2000) found that nurses utilized a rhetoric of “holism” to insist that the duplicated work they shared with doctors was performed in a superior and more caring fashion than the more dominant actors.
To this point, I have presented the literature of internal identity in the face of struggle. What happens to identity if a profession (peacefully) expands, merges or joins with another? Halpern (1992) investigated medical specialties working to increase their autonomy by encroaching on the jurisdiction of another field. Those that were successful in breaking into a previously-controlled area depended upon1) cognitive legitimacy (couching expertise in a common language) and
2) demonstrating that the interests of the interloper were compatible with the larger group.Halpern’s sociology in medicine orientation is not entirely helpful in analyzing the interprofessional relations between CAM and orthodox medicine, however.
The professional dominance of biomedicine leaves a deficit of resources and ecological space from which CAM has to maneuver. This may initiate a movement toward integration with the mainstream, orthodox medical system (e.g., obtaining hospital privileges). The literature documents that when CAM professions attempt to co-exist in an integrative setting with orthodox medicine, that “paradigm assimilation” (Hollenberg & Muzzin, 2010, p. 34) often takes place. One exception to this is the work of Frank (2002) who found that German homeopaths did not disband their traditional, alternative beliefs in order to gain acceptance and legitimacy in the larger health care system. More often, the underlying vitalistic and holistic epistemology of CAM professions is undermined, devalued, and largely omitted. Yoshida (2002) asserts that the “technical” value of CAM disciplines is privileged over “theoretical” value.
Dengele’s (2005) work focuses on the adaptation of homeopathy to the larger environment where the dominance of medicine still figures prominently. Acceptance by the mainstream medicine has led to a fractioning within the discipline of homeopathy creating a tiered system of medically versus non-medically trained homeopaths (Cant & Sharma, 1996). Similarly, Hollenberg and Muzzin (2010) document that new regulation now separates TCM from acupuncture in Ontario, Canada (p. 48).
The first part of this research will examine the micropolitics involved in generating professional identity through a textual analysis of written articles and news stories on the topic. The rhetorical devices used by various segments to assert their views in the discourse will be presented. By focusing on segmental viewpoints represented in text, I hope to demonstrate the existence of multiple, heterogeneous and even contradictory voices engaged in a larger conversation of whom chiropractors profess to be. Additionally, the main thematic issues of contestation around identity construction will be explored.
Extraprofessional considerations and cultural authority
Professions must not only wrestle internally with themselves but then must amend these claims to be acceptable at the macro system level. In this way, professions may try to attain cultural authority and command the legitimacy and recognized expertise recognized by others. The literature suggests that in the US, public support and managed care are two key institutional actors that must be taken into account for professional survival.
Public support and consumer demand have been integral to the growing utilization and acceptance of CAM professions (Pelletier & Astin, 2002). Yet, Pescosolido, Tuch, and Martin (2001) note that public support for professions have been cantilevered with other structural characteristics of the system.When the profession’s attempts at monopoly combine with the financial means to convert political legitimation into institutional support (e.g. insurance coverage) and visibility (e.g., large and impressive medical centers), the public is persuaded in a subtle but nonetheless direct way. The building of institutions crystallizes and reinforces power differences, placing limits on individuals’ attitudes and behaviors and setting a context for individuals’ socialization into a science-based society. (p. 13; emphasis in original)
In this way, public support for professions is part of a more complex institutionalization of professional power in which the dominance of medicine is interwoven with science, and even third party insurance/managed care.
Diagram 1 In spite of initial ideological resistance to Health Maintenance Organizations (HMOs) and managed care in the 1980s, orthodox medical physicians in the US not only expect but may demand to work with these third party payment payers as preferred providers (Hafferty & Light, 1995). Chiropractic’s inclusion under managed care programs has been late-in-coming and then, only in a limited way. Most managed care insurance will cover only a limited number of visits per year, and will not reimburse for X-rays (needed by many chiropractors for diagnosis and analysis) nor for services that are not quantifiable into an acceptable billing/reimbursement code (e.g. wellness care). These financing exigencies set finite parameters within which chiropractic must constitute and present claims of identity and cultural authority.
This research will extend prior research to discuss the way that identity and cultural authority constitute struggles in which multiple, contradictory and heterogeneous claims are made in a discourse within the profession. The ability to constitute an identity is at once agential, but also constrained by structural boundaries and limited resources to define, survive and compete. The following diagram outlines the multidimensional analysis of discourse utilized in this research (Diagram 1).
Methodology
This research utilizes critical discourse analysis (CDA) modeled after Fairclough’s (1992, 1995) work to analyze the heterogeneous discourse surrounding identity and cultural authority within the profession of chiropractic. Specifically, published articles are used as sources of “texts:” utterances which make some form of truth claim and which are ratified as knowledge (Mills, 2004, p. 55).
Although there is no set of accepted methodological procedures to perform CDA, Fairclough (1992) suggests a discourse should be analyzed in three-dimensions:1) the textual level (a thematic analysis of the content of the discourse),
2) the discourse practice level (how discourse is produced, distributed and how subjects are created and positioned), and
3) the social practice level (how discourses are influenced by ideology and the larger social environment).As Luke notes, “CDA sets out to capture the dynamic relationships between discourse and society, between the micropolitics of everyday texts and the macropolitical landscape of ideological forces and power relations” (2002, p. 100). The “critical” aspect of discourse analysis specifically goes beyond mere description to include an interpretation that demonstrates how the discourse is shaped by power and ideology that is often not visible to participants. Fairclough notes that one strategy to investigate this is to capture discourse undergoing a “moment of crisis” to bring into relieve the multiple issues being discussed, as well as making visible the practices that are often “naturalized” or taken as common sense (1992, p. 230). By examining the discourse of identity and cultural authority emergent around the literal moment of crisis announced by Meeker and Haldeman (2002) and the article “Chiropractic at the Crossroads,” I have chosen to analyze the debate occurring amongst chiropractors in the United States as they struggle to create their own sense of identity and project that onto a larger environment of health care providers.
Procedures
The following keywords alone and in combination were used in a search of the Index to Chiropractic Literature (indexed by members of the Chiropractic Library Collaboration) and the newspaper Dynamic Chiropractic: profession, culture, authority, identity, scope, future. Articles published between January, 2002 (the year of Meeker and Haldeman’s “Chiropractic at the Crossroads” article) to December, 2010 were searched. From commonly referenced studies in these sources, three additional unpublished surveys were obtained through weblinks provided. Articles were removed from the initial pool (N = 126) if they were duplicated entries, poster presentations or abstracts at conference presentations without full text to analyze, if the article dealt specifically with issues unique to a country dissimilar to the US (a country where chiropractic was not fully professionalized), or if the article did not deal explicitly with issues of identity, authority or the future trajectory of the profession. This created a database of 98 articles.
A close reading of all texts from the database was performed with an eye to develop a three-tiered analysis. At the textual level, the rhetorical strategies and techniques were categorized to create an overall tone and tenor of debate. The question “who do chiropractors profess to be?” was asked and major themes were allowed to emerge from the data. At the discourse practice level, the question “who is speaking, who is not speaking and how is the speaking being done?” was addressed. Here, the texts were viewed as in interaction with each other, and part of a history of dialog e what Fairclough (1995) would term “intertextuality” (pp.188–189). How the genre of printed publications socially positioned certain voices to be heard while excluding other voiceswas the focus of this level of analysis. Finally, at the level of social practice, texts were examined for connections with the larger socio-political context in which the debates are situated. The following two questions: “how is the profession projecting itself?” and “to whom are these images being presented?” were posed. With consideration of existing power relations in the health care environment, the external organizations, professions and institutions most affected by issues of identity and cultural authority for the profession were also identified.
Reflexivity
As Smith (2007) and Finlay (2002) note, it is important for researchers utilizing CDA to be explicit about their relation to the topic or participants through which the researcher has interpreted the texts. I was initially sensitized to the discourse surrounding cultural authority when I was invited to speak at the Association of Chiropractic Colleges e Research Agenda Conference several years ago. This conference is attended by chiropractic college faculty, administrators, researchers and policy-level decision makers. Feise (2005) estimates that only a few dozen full time practitioners attend the conference (p. 20). Having just completed a dissertation that involved archival research as well as in-depth interviews with veteran “everyday” chiropractors, I was struck by the disjuncture in orientations between what I come to distinguish in this research as two distinct characters: the everyday chiropractor versus the academic chiropractor.
In the interest of full disclosure,my spouse is a chiropractor who over the course of my career has gone from being an everyday chiropractor to a chiropractic college faculty member and now a college administrator/academic chiropractor. Rather than seeing my position as biased, I see it as akin to Collins’ (1986) “outsiderwithin” perspective. I am an outsider and not a chiropractor, but am “within” because I am on the margins of both the everyday chiropractor as well as the academic chiropractor, having been married to one, having interacted with dozens of chiropractors (both academic and everyday) and having researched the profession as a whole for over a decade.
To ensure validity and trustworthiness, I have worked to examine as wide a range of voices as possible (albeit only those that have been published and heard) asking consistent analytical questions of each text, as suggested by Smith (2007). Following the lead of Finlay (1998, 2002) I was conscious of instances where my own feelings and experiences ran contrary to those reflected in the texts. I remained vigilant to differences and divergences and embraced all as valid viewpoints. I do not claim to have achieved a value-free analysis, nor do I believe that I have presented the “one correct reading” of the texts under examination. In fact, to do so would run contrary to the principles of CDA, as it should be understood that texts are “socially constructed by and, in turn, construct understandings of reality rather than describing a or the reality” (Cheek, 2004, p. 1147; emphasis in original). I have acknowledged my background so that the reader can understand the possible influences on the interpretations in this research.
Aside from the issues of reflexivity mentioned above, the methodology employed in this research is limited to written and published texts. It is possible than an article from the initial pool was overlooked and omitted during the selection process, although the author and a graduate assistant both performed the selection process separately with identical results. Additionally, not all viewpoints from chiropractors are represented equally. Opinions that were never recorded or printed, those outside or dissimilar to the US context, and those written in a language other than English were not included in the database.
Findings
Textual level
At the textual level, analysis can either be intensively investigated linguistically and semantically (Threadgold as suggested by Fairclough, 1992, 2003) or can be conducted at a more thematic level (Threadgold in Kamler, 1997, pp. 437e438). Similar to the approach of Threadgold as well as Smith (2007) this research will examine the rhetorical techniques and larger thematic patterns that emerge in the texts to elucidate the areas of debate, crisis and proposed identity within the profession.
Rhetorical devices
The texts reveal a tapestry of many heterogeneous voices. Although a multitude of perspectives emerge, there are some repeated rhetorical strategies:1) threat,
2) divisiveness, and
3) the ideology of science.These devices are similar to what has been noted in prior research (Warnock, 2005; Welsh et al., 2004).
Threat
There is a dire sense of emergency and an explicit call to action in many of the texts. Change is imperative inferring that death or some disastrous consequence might ensue. One commentary makes this clear: “Chiropractic, as a profession, is endangered. Its practitioners are soon to become clinically extinct. This is not a drill” (Filippi, 2005, p. 1). Other words used in the texts to indicate a sense of threat include: assault, nihilistic, eaten alive, and crisis point.
Divisiveness
It is also clear there is considerable disagreement and debate concerning professional identity within chiropractic (see further discussion, below). Rather than framing a persuasive yet dispassionate argument, the discourse features a great deal of emotional and rancorous name-calling in an effort to distance one segment from another and to denigrate colleagues as an undesirable “other.”
Feise (2005) states he is “embarrassed” by his fellow chiropractors for their lack of research experience and knowledge. He further questions their intelligence: “most doctors of chiropractic are incapable of defending themselves.” (p. 21). Demarcation from undesirables extends to privileging chiropractic as superior to other CAM practitioners. Gleberzon, Cooperstein, and Perle (2005) assert that the profession of chiropractic must reign in unethical practitioners at the margins or else “perceptually if not legally be demoted to a ‘Group B’ status, lumped together with homeopaths, acupuncturists and massage therapists” (p. 72).
“Discourse” is somewhat of an overstatement when analyzing these texts. The corpus of publications as a whole involve numerous statements meant to provoke but not to converse; meant to hurt rather than to understand; meant to claim victory rather than interact. There is much more talking at rather than actual dialog occurring.
Ideology of science
The most common rhetorical strategy is to wage that a segment is not committed to science and the assumed rationality and objectivity that come with such an orientation. As a result, segments that do not embrace science in an appropriate way (by subscribing to a progressive lexicon and advocating evidence-based practice) are by default emotional, irrational and illogical. Murphy, Schneider, Seaman, Perle, and Nelson (2008) equate a segment of chiropractors (to be later identified as “subluxation-based chiropractors) as occupying the same metaphysical and pseudoscientific space as foot reflexology (Podiatrists and Foot Reflexologists section, para. 2), while Phillips (2004) castigates this segment as akin to “creationists” and “fundamentalists” (p. 6). He goes on to privilege the position of progressive chiropractors (to be later identified as back/neck/pain specialists) as having created “a soul willing to search for truth, to challenge the status quo in hopes of making it better” (p. 10).
Perhaps the irony is that most authors that elevate science on a pedestal as both the means and ends of professional change assert that their segment is much more proficient and knowledgeable of scientific practices than the other segments in chiropractic. However, science is really much more of an ideology. Phillips (2004) who speaks as part of the segment advocating limited professional status, pleads for chiropractors to be scientifically rational, yet presents personal communication from two chiropractors as his “evidence” to do so. Good (2010a, 2010b) critically notes that those who demand science as the arbiter of what should be practiced are the very ones that employ a selective interpretation of only some of the available evidence to support their agenda. For the back/neck/pain specialist segment who include many chiropractic leaders, science is an ideology to be pronounced for political expediency and as an expectation for others, but often not themselves, to meet.
Thematic textual analysis
The CDA utilized in this research also involves a thematic analysis of the major issues of contention in the discourse surrounding identity within the profession. I present five different axes around which identity is actively debated within chiropractic today: 1) scope of practice, 2) application and treatment, 3) alternative or mainstream positioning, 4) lexicon, and 5) service.
Scope
I am using scope of practice here to refer to claims of the appropriate jurisdictional niche of the profession. Setting a narrow scope as neuromusculoskeletal spine experts or back/neck pain specialists has been advocated by several segments within the profession (Mootz, 2007; Murphy et al., 2008; Nelson et al., 2005; World Federation of Chiropractic (WFC), 2005). Others are vehemently opposed to this (Duenas, Carucci, Funk, & Gurney, 2003; Kent, 2009; Riggs, 2007; Rosner, 2005; Sportelli, 2006). Smith and Carber (2009) report that 73% of surveyed chiropractors considered themselves as “back pain/musculoskeletal specialists” (p. 23). Yet inconsistently, another international poll found that 47% of chiropractors felt that serving as “back and neck pain specialists” was the least desirable image of the profession to have (WFC, 2005, Survey of the Profession section, item 4e).
Contrarily, another segment in the profession seeks an expanded scope of practice and aspires to capture a new area of jurisdictional expertise: wellness. Hawk (2004) analyzed college mission statements and scope of practice definitions in all 50 states, and found the common descriptors to be “primary-care providers who emphasize health and help the body heal itself” (p. 46). An international survey of practicing chiropractors found the most desirable image of chiropractors (83%) to be “wellness doctors” (WFC, 2005, Survey of the Profession section, item 4e).
But, even among those that advocate wellness there is disagreement over how broad this scope should be cast: as patientcentered, part of public health, as doctors of natural medicine, or as personal well-being? Gatterman (2006) suggests “a patientcentered paradigm that provides a model for health promotion and wellness in the patient’s interest” (p. 95) that is soundly restricted to only scientifically-verified techniques. A vocal segment within the profession is pushing for chiropractic to become a part of the American Public Health Association (APHA) (Hyland & Baird, 2005; Johnson et al., 2008; Murphy et al., 2008). This would enable chiropractic to ride on the coattails of the APHA’s sizable membership, resources and lobbying efforts and could expand the range of insurance codes chiropractors could seek reimbursement under to include preventive medical care. To do this, chiropractic would need to expand their daily routines to include screening for risk factors, health behavior counseling (e.g., weight reduction, smoking cessation) and abandon a historically-held anti-vaccinationist stance. This becomes problematic when considering that McDonald’s survey of practicing chiropractors found that 50.1% believed the pro-immunization stance of medicine deserves to be questioned (2003, p. 60).
Riggs (2007) proposes an even more aggressive scope to become comprehensive doctors of natural medicine and suggests that chiropractic merge with naturopaths and then focus on herbal, nutrition and functional aspects of health care, women’s health and gerontology. Still others propose a nearly all-inclusive usage of the wellness platform. This segment sees wellness as an opportunity to address any and every aspect of health, and away to tie the vitalistic roots of the profession by addressing “wellness, quality of life and human potential” (Kent, 2009, p. 31). These chiropractors seem to equate wellness with personal well-being and aim to address concerns that go beyond physical symptomatology to include emotional, spiritual and psychological aspects of health.
Application and treatment
Abbott (1988) states the essential feature of a profession is the work that they do. For chiropractic, this involves debate over the treatment of patients and whether a conservative or liberal set of work prerogatives are more appropriate.
Chiropractors are debating the proper application of care. On one end of the spectrum are chiropractors who advocate handsonly adjustment of the vertebral spine. Winterstein, Phillips, and Kremer (2004) suggest calling this traditional and conservative segment “subluxation-based chiropractors” and contrasts it with the more liberal and progressive “physicians of chiropractic medicine:” who “provid[e] differential diagnoses, manual medicine, nutritional products, natural and physical medicine services” (p. 20). The segment advocating chiropractic medicine has been working legislatively to amend educational accreditation standards to recognize this doctor title along with removing the phrase “without drugs and surgery” which would open the floodgates to prescription drug-writing abilities. Abandoning the drugless stipulation of alternative medicine has already been accomplished in revisions to chiropractic scope of practice laws in New Mexico (c.f., Clum, 2010).
There does appear to be consensus over allowing chiropractors a wide range of treatment options. In an investigation of selfreported actual practice by chiropractors in North America, McDonald (2003) found a wide range of care (treatment) deemed “acceptable” within the purview of chiropractic: prescribing vitamins/ minerals: 96.7%; modalities [electric muscle stimulation, ultrasound] 93.5%; massage 93.1%. Also, chiropractors in this survey reported a wide range of practice prerogatives (application) that they actually performed beyond the adjustment/manipulation, such as: exercise recommendation: 97.8%; and stress reduction recommendations: 86.4%. Similar results were obtained in a national survey of UK chiropractors (General Chiropractic Council (GCC), 2004). Clearly, chiropractors in everyday practice are employing an expanded application and broad range of treatment for their patients, but this does not extend as far as a desire to write prescriptions. Only 11.4% of chiropractors surveyed by McDonald (2003) felt chiropractors should be able to write prescriptions for all medicines (p. 52) an indication that the segment advocating “chiropractic medicine” is not representative of the whole profession.
Alternative or mainstream positioning
A third criteria central to intraprofessional identity concerns the degree of autonomy desired by the profession. That is, should the profession remain peripheral and part of CAM, or should it integrate and become part of the mainstream?
One segment of chiropractors seeks integration (Lehman & Suozzi, 2008; Morgan, 2005; Taylor, 2006). Proponents of this view envision increased respect and access to biomedical institutions:The benefits of integration to the profession are too great to ignore. To be part of the system is to have access to all the resources of the system — funds for research, state supported education setting, access to other educational institutions and nearly universal inclusion in all reimbursement systems. (Nelson et al., 2005; Integration section, para. 5.)
Branson (2009) presents some of the only direct reporting of actual integrative practice involving chiropractors working alongside physical therapists in a hospital setting in Minnesota. Although a pioneering achievement, the “integration” involved less than 10 chiropractors (whose numbers have been on the decline in more recent years) isolated to an off campus facility which seems to reinforce the findings of Hollenberg and Muzzin (2010) who found that these arrangements were more co-opting and marginalizing than integrative.
Chiropractors in actual practice seem to reject both the alternative and mainstream ends of the continuum. As Redwood, Hawk, Cambron, Vinjamury, and Bedard (2008) note, 69% of their nonrandom sample rejected the label “CAM,” but also rejected the labels “integrative medicine” and “mainstream medicine” (p. 368). No other label achieved consensus in the sample, either. The potential movement of chiropractic from a marginal to a limited status brings with it “definitional vertigo,” (p. 366) at least for everyday chiropractors.
Lexicon
Also relevant within discourse is the choice of lexicon used by various authors laying ownership to certain vocabulary and disparaging the use of other terms.
Fairclough (1992) writes:One focus for analysis is upon alternative wordings and their political and ideological significance, upon such issues as how domains of experience may be “reworded” as part of social and political struggles. or how certain domains come to be more intensively worded than others. (p. 77)
Chiropractic’s early history as “separate and distinct” proved an effective legal defense for chiropractors arrested for practicing medicine without a license (Rehm, 1986). This rebel status extended to the use of a unique lexicon that included such concepts as subluxation and Innate Intelligence. These terms that were once sources of pride are now seen by some segments as an embarrassing stigma that needlessly ties the profession to antiquated notions of self.
Of chief debate is the concept of subluxation, or vertebralesubluxation complex (VSC). Viewed allopathically, a subluxation is defined as a partial dislocation of a joint which should be removed or (biomedically) corrected (c.f. Kaptchuk & Eisenberg, 1998). The concept subluxation is inextricably tied to the underlying vitalistic and holistic epistemology of chiropractic. Viewed in this way, the subluxation is not only a blockage of nerve flow (a physical entity) but also a (as yet unmeasurable) interference of mental impulse and expression of Innate Intelligence (conceptualized as any form of life: physical, mental, spiritual, psychological). It is undetectable and may be asymptomatic, signaling a state of “dis-ease” in the body.
A segment of chiropractors (often including the subluxation-based chiropractors, mentioned previously) wish to remain tied to the original philosophy of the profession and do not wish to make a diagnosis as that limits attention to a symptom or condition rather than a holistic orientation of overall health and functioning. They believe the body can vitalistically restore the mental impulse but does so inways that defies reductionist science and hypothesis testing. The result may be a desirable and measurable health outcome (e.g. lowered blood pressure, lower pain); however, it is just as possible for higher blood pressure, heightened pain or no physical manifestations to immediately result. The response is what the body needs, rather than what science can accurately predict. As Chestnut asserts, chiropractic is more than just a mechanistic adjustment aimed at curing or treating a specific diagnosis.Manipulation may indeed by one of the best therapies in the world to decrease pain, but it will never be a feather in the cap of chiropractic. Reducing subluxations reduces pain and symptoms but this is no more than a welcome, beneficial and lucrative side-effect to correcting VSC, improving function, and removing interference to the innate ability of the body to self-heal. (2008, Thinking Globally section, para. 4).
The lack of scientific validation of the subluxation has attracted considerable ire in recent years. One segment within the chiropractic profession feels it important to transcend this lexicon and its philosophical attachments (Good, 2004; Winterstein, 2002). Most of the chiropractors who advocate removing subluxation from the lexicon have taken a more allopathic approach to chiropractic, and also advocate becoming back/neck/spine specialists or limited professionals.
As Fournier (2001) and Warnock (2005) both note, rhetoric may be used to initiate movement toward preferred ideals. By castigating subluxation-based chiropractors as dogmatic zealots, an “other” is fashioned, against which a segment of the profession is attempting to define themselves. The back/neck/pain specialist segment argues that terms like subluxation, Innate Intelligence and vitalism are to be banished from the profession and considered only as “a personal matter so long as these beliefs do not distort the discharge of professional duties and obligations” (Nelson et al., 2005; What is the Chiropractic Hypothesis? section, para. 5). Philosophy, they propose, should be referred to instead as a “refutable theory” or “hypothesis” (and therefore, something that can be falsified and disbanded). One proponent states: “The fixed ‘single chiropractic concept’ [subluxation] that some struggle to keep alive has for them unfortunately past (sic) on, as has bloodletting, wooden teeth and the Flat Earth Society” (Carter, 2005, p. 10).
The segment wishing to move to limited professional status seems impatient and no longer willing to discuss the matter because of the presumed size of their group and a history of unsuccessful communication with the other side:There can be no unity between the majority of non-surgical spine specialist chiropractic physicians and the minority of chiropractors who espouse metaphysical, pseudoreligious views of spinal subluxations as ‘silent killers.’ The latter minority group needs to be marginalized from the mainstream majority group and no longer should unrealistic efforts be made toward unification of these disparate factions within the profession. (Murphy et al., 2008; Podiatrists and Foot Reflexologists section, para. 3).
Yet, polls of practicing chiropractors are strongly in favor of retaining their distinctive lexicon. McDonald (2003) found:
For all practical purposes, there is no debate on the vertebral subluxation complex. Nearly 90% want to retain the VSC as a term. Similarly, almost 90% do not want the adjustment limited to musculoskeletal conditions. The profession as a whole presents a unified front regarding the subluxation and the adjustment. (p. 20).
The views of everyday chiropractors as indicated in surveys are discrepant from the pronouncements by their chiropractic leaders.
Service
Parsons (1951) noted the key characteristic of a profession was its service orientation. True professionals operated with fiduciary obligation toward their clients, placing the client first (collectivity orientation) regardless of the inconvenience or sacrifice this meant for the professional (self orientation). One chiropractor, Kisinger (2009) stated “pursuit of affluence, entitlement and personal excess as the ultimate calling and reward.” has displaced a commitment to beneficence (p. 44). Many within the profession target practice-management groups where chiropractors are taught hard-sell techniques aimed at achieving short-term wealth for the individual. These techniques are unscrupulous because they rely on intimidation and fear tactics and often dupe patients into visits that are not needed or are excessively drawn-out so as to financially exploit them. One chiropractor offers these concerns:For example, some practice consultants promote the policy of withholding administration of treatment on the first visit, preferring to reschedule the patient for a report of findings on a subsequent visit. Others promote the use of X-rays on nearly every patient in order to determine biomechanical deviations from a theoretical “model” of a normal spine implying that this information is so essential to successful treatment that the benefit outweighs the very real risk of radiation exposure. These and other business practices promoted across the profession are tolerated without challenge by the rank and file. (Nelson et al., 2005; The Search for Cultural Authority section, para. 5).
Fournier (2001) found something similar in aromatherapy when the idea of the “quack” was evoked implying an inappropriate commitment to profit using any means necessary. Welsh et al. (2004), too, seem to touch upon a similar phenomenon noting that charismatic leaders were divisive within homeopathy in Canada, pulling followers in divergent directions and toward alternate visions and identities. In chiropractic, charismatic personalities that offer practice-building seminars and life coaching, coupled with allegiance to subluxation-based chiropractic have existed for decades (Baer, 1996; Haneline, 2005; Keating et al., 2005). Kisinger (2009) voiced concern that these practice-management organizations targeted the profession’s young, who are impressionable, or those facing fiscal distress. (Gleberzon et al., 2005).
The discourse surrounding intraprofessional identity is the most contentious area for the chiropractic profession. No clear division of camps can be noted. Those segments that are conservative in the area of treatment/application may be liberal in the area of scope and then once again conservative when it comes to autonomy. The same segment that opposes another on the issues of scope of practice may very well be united on issues of service. Some segments are not well represented in the chiropractic literature at all. They do not publish their views, but rather circulate them in seminars and conferences led by charismatic leaders. Each issue is a separate line of fault leading to dissensus on identity.
The issues scope of practice and lexicon are most contested, and the profession as a whole cannot agree on whether to remain alternative or join the mainstream. Service is much less debated and there appears to be consensus on the issue of treatment but not application. The discourse, itself, is characterized by the rhetoric of threat, divisiveness and an appeal to the ideology of science. The level of dissensus documents that there are multiple, contradictory and heterogeneous voices within the discoursedparticularly a gulf between chiropractic leaders and everyday chiropractors, as well as subluxation-based chiropractors and those who advocate becoming back/neck/pain specialists. This muddied notion of self makes co-existing and competing at the macro level more difficult.
Discourse practice level
Fairclough notes the discourse practice level involves the “production, distribution and consumption of texts” (1992, p. 78). Specific genres of discourse (e.g., newspapers) contain conventions and rules that operate to “control linguistic variability for particular areas” (Fairclough, 2003, p. 24). The goal in this section is to determine the dominant, contradictory and/or silent voices within the texts and what functions they serve. The sources analyzed in this research are 1) peer-reviewed chiropractic publications, and 2) news stories from Dynamic Chiropractic, the major periodical of the profession.
Texts are shaped discursively, so there is a controlled way in which questions are asked, answers are presented and information is expected to be conveyed. Imploring the chiropractic profession, Hawk (2004, p. 45) notes: “if it is not published, it didn’t happen!” which denotes the exclusionary character of publishing in the academic press. What is unsaid here, is any author must have the acumen to present, cite, research and organize ideas in away that is parallel, rigorous and worthy of inclusion into the peer-reviewed marketplace of printed research. Peer-review also operates as a filter where alternative voices and opinions may be rejected because they lack alignment with the dominant discourse, lexicon and method expected in a journal. In newspaper sources, columnspace, topicality and relevance are criteria held at the discretion of editorial staff. Again, alternative voices (e.g., letters to the editor, press releases) may or may not be published (Villanueva-Russell, 2009). The vast majority of texts in this research (78%) come from peer-reviewed journals, so the bulk of analysis will be devoted to that particular media source. Within this discourse the conventions of journal publications elevate the academic chiropractor segment and those advocating a science-oriented, back/neck/pain specialist position while structurally limiting the ability of everyday chiropractors as well as subluxation-based segments from having their views voiced.
Conventions of academic publishing
Welsh et al. (2004) note an increasing impetus for CAM professions to accommodate medical science and research. But, this endeavor has been difficult for chiropractic due to a lack of infrastructural support necessary to fund and sustain biomedical research (Keating, Green, & Johnson, 1995). Not only does chiropractic lack the institutional basis to conduct its own studies, the outlets in which this is done are clearly structured toward biomedical research that relies solely on a positivist methodology in which randomized controlled trials are privileged. Research is done without consideration of the epistemology of CAM. As Nelson (1997) notes “clinical studies of the effectiveness of spinal manipulation are conducted and reported without reference to the presence or absence or even the existence of subluxations” (p. 46).
Young (1998) detailed that even after the Office of Alternative Medicine (which eventually evolved into the National Center for Complementary and Alternative Medicine e NCCAM) was created, the initial funding went to major research institutes that proposed allopathic research (such as evaluating cartilage products and antineoplastons for cancer prevention and treatment) (p. 293). The NCCAM and some researchers (c.f. Tataryn, 2002) classify chiropractic as a “manipulative and body-based therapy” rather than as an “alternative medical system,” so a bias exists toward studies that mechanistically focus on the effects of treatment, only (Redwood et al., 2008, p. 362). This then adds ammunition for those desiring limited professional status as back/neck/pain specialists. Reductionist, positivistic research demanded by evidence-based practice divorces the underlying philosophy (of which subluxation-based chiropractors are advocates) to mere therapies or procedures. Tang aptly writes that a similar process in acupuncture is a: “process not unlike completing a jigsaw puzzle using scissors” (2006, p. 259).
Everyday chiropractors and the subluxation-based segment are not represented well in the discourse. Not only are they not engaged in research or authors of peer-reviewed publications, their views are only indicated by proxy through surveys and unpublished polls. Further, each of these sources are methodologically flawed and suffer from small sample sizes (Smith & Carber, 2009), selfreports of activities (McDonald, 2003) and non-random samples (WFC, 2005) which mean that the views of this segment are partial and incomplete, at best.
Discourse technologists
Fairclough notes that the underlying power relations and ideology of society also underlies a discourse. His main emphasis is on the effects of the “new capitalism” and how this has triggered the “technologization of discourse” (1995, p. 102). Perhaps the “scientization” of CAM seems to underlie much of what is occurring at the discourse practice level found in this research. Fairclough (1995) notes that the “discourse technologist” plays a crucial role in disseminating this new orientation. “This is done through a process of redesigning existing discursive practice and training institutional personnel in these redesigned practices” (1995, p. 102).
Fournier (2001) notes in aromatherapy, those evoking a professional trope projected an image of “disinterested gentlemanly scientist” (p. 124) who were objective, rational and solely in pursuit of truth and knowledge. A similar stratification seems to be developing within the chiropractic profession as a segment of academic chiropractors serve as discourse technologists who are at the root of the majority of articles in which science-oriented change toward becoming back/neck/pain specialists is advocated They evoke authority through their degrees, leadership positions and institutional positions in education, journals and chiropractic associations.
This small group of researchers has worked with remarkable cohesion and productivity: generating a research agenda, white papers and a strategic plan to mark their future priorities (Lawrence & Meeker, 2006; Triano et al., 2010). Their ideological underpinnings of integrative alignment with the medical model set the foundation for efforts to standardize lexicon and research practices, reform licensing and scope of practice standards profession-wide. In this sense, the discourse practice level is dialectically linked to the textual level. Professional identity is constructed agentially by chiropractors, but is also constituted and constrained by the activities at the discourse practice level, and specifically, the actions of discourse technologists/academic chiropractors.
Two examples of this are separate efforts to reach “consensus” on key terminology for stages of care (Dehen, Whalen, Farabaugh, & Hawk, 2010) and on a strategic research plan (Triano et al., 2010). In both cases, a select group of chiropractors made policy-level decisions, then published and announced these in an attempt to standardize practice and “naturalize” activity (Fairclough, 1992) thus rendering the discourse closed and ruled upon. But, by their own admission, the strategic planning consensus conference began with the “assumption that successful future [professional] growth requires cultural change” (Triano et al., 2010, p. 396).
So, tradition and concerns of subluxation-based chiropractors were never represented, entertained or considered as valid viewpoints from which to construct a future trajectory. In the case of a consensus conference to standardize terminology, the authors (Dehen et al., 2010) admit that agreement on definitions to be used for terms such as “wellness” and “acute” were determined by only 27 participants, of which only three were non-chiropractors, two-thirds belonged to one single chiropractic association and nearly a quarter also served as consultants to third party insurance payers (p. 460). Establishing lexicon or a research trajectory by a specialized subset of academic chiropractors in isolate from the larger practicing population of practitioners ensures that nothing close to an “ideal speech situation” (Habermas, 1990) or true “consensus” will result.
At the discourse practice level the conventions of peer-reviewed journals privilege the voice of chiropractors that wish to become limited professionals while silencing those who prefer to remain marginal. The academic chiropractors assume a dominant voice in the discourse not only because they use their degrees and positions to legitimate their voices, but also because they are in gatekeeping positions that control access to journals, the content of these articles, and the lexicon to be used within the profession. In this sense, the discourse practice level is dialectically linked to the textual level, as identity is both shaped yet constrained by the discourse.
Social practice level
Analysis at the social practice level situates the discourse in the larger socio-political and historical context to see how ideology has shaped the dialog. Discourse affects social relations and the identities of those within them. The focus of this section is to examine the debates over identity as they are situated in a larger context of existing power relations. The structural features of the US health care landscape shape the discourse and efforts to project the cultural authority of the profession, as well.
Public
Appealing to the public is important. Without clients and patients, doctors cannot financially survive. However, the public adjudication of claims cannot wholly be manipulated or predicted. The public seems to have a long-term memory of professions, and these images are not easily molded or altered (Abbott, 1988).
Claims of cultural authority must be projected in spite of unfavorable stereotypes of chiropractors as “back crackers.” One professional segment has decided to turn the stereotype into a more positive image as “spinal care specialists” (Briggance, 2005; Murphy et al., 2008; WFC, 2005). Briggance (2005) reasons that chiropractic should simply align themselves with the public’s image because that is what chiropractors do, anyway. “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” (p. 14).
The suggestions to model in the public’s preferred image are not unilaterally supported within the profession. One critic argues “It is merely a daisy chain of mind games.It would truly be a comedy of errors e to say nothing of a tragic mistake e to cast the future image of chiropractic’s potential exclusively on what one believes the public wants to hear” (Rosner, 2005, pp. 43e44). Defensively catering to the public’s misinformed image of the profession seems contrary to asserting expertise through claims of cultural authority.
Market
Others within the chiropractic profession advocate shaping authority around what the public demands, but justifies this in terms of economic exigencies. Greenawalt (2004) believes that hiring a public relations firm to create a marketing “brand” for chiropractic is the most prudent strategy. Utilizing a metaphor of the nearly-bankrupt Winn Dixie chain of US supermarkets to suppose a similar fate for chiropractic, Sportelli states: “Our success (or lack of success) in establishing a credible, coherent, ethical identity in the minds of the consumer is the only and final arbiter of market share. Regardless of what we claim to be, unless our image is congruent with public perceptionsdour customersdnothing else matters” (2005, p. 26).
Insurance
Another major actor within the US system of health care professions is third party insurance and managed care. Managed care is an external force that directly impacts acceptance of chiropractic in the larger health care system. As managed care reimbursement is clearly set up to reflect the structure, diagnostic language and practices of biomedicine, many chiropractors argue that altering identity, lexicon and practices toward allopathic, painoriented conditions is necessary for survival in today’s world. To maximize insurance reimbursement, lexicon cleansing is necessary.[F]or the theory [philosophy of chiropractic] to be embraced by the greater social system, it should offer implementation that can fit within constraints of the existing system. A theory that requires the elimination of the two entire industries of medicine and insurance will probably not be embraced in Western cultures no matter how feasible and promising it might be. (Mootz, 2001, p. 7)
Others argue that chiropractic has been sabotaged by the very attributes of professional status it fought so hard to attain. Achieving reimbursement in third party insurance brought the opportunity to obtain profit through creative billing and over utilization (Gleberzon et al., 2005). The irony in becoming a profession was that status was attained at the cost of a service orientation, a self-limited scope of practice, and distortion of application to appease others. As one chiropractor reflects:
The evidence to support my contention is clear to the field practitioner who witnesses the erosion of economics, authority and influence almost daily. Medicine and the insurance payers pointed us to a set of diagnoses that we currently claim to be experts for. We willingly took the bait in expectation of money. We systematically abandoned the claims that we treated those other diseases that they didn’t want us to treat. We did this with little concern for the patient and not much more for our profession. We did this for immediate satisfaction, mixed with greed and low self-esteem, searching for something to create our identity. (Sportelli, 2006, p. 77)
The extent to which chiropractic seeks inclusion within third party payment schemes remains undetermined. If chiropractic seeks continued inclusion within managed care, this will surely mean an increasingly narrow scope of practice and diminishing returns in terms of reimbursement into the future (Hyland & Baird, 2005), unless perhaps it can gain authorization to utilize the preventive medicine insurance reimbursement codes available to public health.
Science
Science is an epistemic movement that is larger and external to the system of health care professions. This demand for empirical proof has triggered an “audit culture” (Shore & Wright, 1999) obligating professions to demonstrate measurable health outcomes. Evidence-based practice (EBP) is one indicator of this movement within health care today.
Chiropractic has wedded itself to the ideal of EBP; however, this benchmark has been difficult for the profession to meet, partly because there is a lack of infrastructural support for research in chiropractic educational institutions (see Section Discourse practice level for more on this). The protocols of EBP are more aligned with the segment of chiropractic that favors becoming limited professionals (back/neck pain specialists) because EBP has not been able to validate the philosophical orientation of subluxation-based chiropractors, such as the existence of the subluxation, Innate Intelligence, nor has there been enough valid scientific study to provide support for such widespread practices as wellness care, pediatrics and animal chiropractic (Villanueva- Russell, 2005). This means that the majority of care actually provided and deemed acceptable by the majority of chiropractors reported in national surveys (GCC, 2004; McDonald, 2003) should in theory, be deemed unacceptable and accompanied by the disclaimer “this procedure does not have strong backing from high quality systematic reviews of all available relevant scientific studies” before being performed on any patient (Nelson et al., 2005; The Acceptance of Evidence Based Healthcare section, para. 4).
The imperative for EBP from the larger health care environment translates to pressure and constraints that impact the practice of everyday chiropractors. Those advocating EBP also advocate for chiropractic to evolve into a limited professiondone in which the scope, application, treatment and lexicon are self-circumscribed to be aligned with that which can be verified through science. This process appears to be well underway internationally. Revisions by regulatory bodies in both Great Britain and Australia have amended the Code of Conduct standards for chiropractors to eschew use of the term subluxation or VSC because they lack clinical research evidence (Chiropractic Board of Australia, 2011; GCC, 2010). Additionally, the GCC’s revised code also calls for the allegiance to science to trickle down to the practice of advertising and reiterates a service-oriented imperative for the profession: “when advertising, claims for chiropractic care. ‘must be based on best research of the highest standard’ only” (GCC, 2010, n.p.).
Conclusion
The notion of Meeker and Haldeman’s (2002) “crossroads” is still unresolved nearly a decade later. There is considerable disagreement on scope, autonomy and lexicon. External pressures create a need to remain financially viable while accommodating science. Efforts to construct professional identity are made difficult because of power struggles between intraprofessional segments. Those advocating changes are differentially positioned and so have a greater impact on the shape and content of the discourse.
Should chiropractic sequester itself to become an evidence-based, back and neck pain specialty that is integrated with medicine as professional leaders have proposed? Pressure from insurance, the market and science all operate to produce momentum toward this end state. What are the potential consequences of this limited professional status? Robbins notes that “political self-betrayal” (1992, p. 3) may occur inwhich some are accused of selling out their ideals and philosophy for status. Segmental differences may be heightened rather than diminished, as was the case internationally for acupuncture (Hollenberg & Muzzin, 2010) andhomeopathy (Cant & Sharma, 1996). If integration means limiting the scope, truncating the application and abiding by only those aspects that can be scientifically demonstrated, then assimilation and co-optation are much more likely outcomes than integration.
Contrarily, everyday chiropractors are content with the current status quo as marginal professionals, wishing to remain tied to the traditionalist lexicon and an expansionist range of application and treatment authority. Until the market position, self interest/profit, or range of treatment prerogatives are affected, the identity crisis of chiropractic will not become a true reality nor a cause for concern for this segment of the profession.
While a heterogeneous and often contradictory discourse on both identity and cultural authority is present, the ideological underpinning of each segment and the timing of this “moment of crisis” remains unpacked. It is worth asking why these debates are occurring at this time. There is no ensuing crisis and no external imperative to reshape or initiate discourse on this particular topic. Redwood et al., echo this point:No governmental body is demanding it. There is certainly no groundswell in the CAM community to eject chiropractors (who, after all, make up the largest cohort of CAM practitioners as defined by NCCAM). Moreover, it would be a drastic overstatement to assert that MM [mainstream medicine] is rolling out a rainbow-colored welcome mat for chiropractors. (2008, p. 368)
Analysis of the discourse suggests that debate over identity and cultural authority seems largely a politically-motivated intraprofessional movement, focused more on paternalistic occupational control than over cohesion and unity. Hollenberg and Muzzin’s (2010) work on paradigm appropriation of acupuncture in Britain does not wholly seem to apply to the case of chiropractors in the United States. Rather than seeing the dominance of biomedicine engulf a subordinate marginal profession, the impetus to engage in paradigm assimilation (integrative medicine or the idea of becoming a back/neck/pain specialist) is being driven from within the profession of chiropractic, itself. Rather, changes to identity are being initiated internally by academic chiropractors as a coup d’état using the commitment to science (seen operating at the textual, discourse practice and social practice levels through EBP, lexicon cleansing and reformed scope of practice laws) to achieve intraprofessional control.
The growing divide between the everyday chiropractor whose views are only available by proxy through methodologically flawed surveys are being systematically silenced by the claims of academic chiropractors, who utilize rhetoric, status, institutional position, and their roles as gatekeepers to journals as a means to dominate the discourse. As Harding (1998, p. 145) notes: “Truth claims are a way of closing down discussion, or ending critical dialog, or invoking authoritarian standards.” Perhaps the idea of crossroads should more appropriately be replaced with “crosshairs.”
One could also ask whether the debate over professional identity and cultural authority has any actual basis at all, or whether it is mere a by-product of intellectual fashioning of academic chiropractors. Surveys provide a glimmer that everyday practitioners vary in their views, although no systematic studies exist to date to empirically document their voices. It could very well be that an analysis of the discourse of everyday chiropractors (through indepth interviews, CDA of conferences attended by these practitioners, etc.) would reveal an equally diverse, contradictory, rhetoric-filled conversation. Good (2010a, 2010b) presents his personal views as a “centrist” who is part of the “silent middle majority” in chiropractic that wishes to take a more moderate stance on issues of lexicon (p. 33). He suggests that this mass of chiropractors could decide the future direction of the profession, but at this point have not been mobilized to act as a collective unit. “We must become vocal about directing our research initiatives. To sit by idly and hope that this is accomplished without the centrists will only allow those at the fringes to continue their destructive ways and continue to allow the profession to evolve into an entity that does not represent the majority” (p. 38). Whether these everyday chiropractors have something unique to say that would reinforce or challenge the academic chiropractors has yet to be determined.
However, to allow everyday chiropractors meaningful participation in the discourse over professional identity and cultural authority would certainly be beneficial for the profession, as a whole. The science-based research and EBP created by academic chiropractors could be complemented by what Gabbay and Le May (2010) describe as “mindlines” or tacit knowledge gained from the practical clinical experience of the everyday chiropractors. Rather than strong-arming change that may be contradictory to the preferences of chiropractors, incorporating mindlines and insights from actual practice could help to bring context, the complexities of the real world and the challenges and exigencies of a clinical practice to balance the more rational and purely scientific guidelines often created by academics (that are just as swiftly ignored by practitioners). Allowing everyday chiropractors to contribute to policy decisions will ensure a more representative professional dialog, as well as encourage buy-in. As Gabbay and Le May (2010) note, a consideration of mindlines possessed by everyday practitioners coupled with the more formal knowledge of academics could help bridge gaps between theory and practice and encourage actual implementation of guidelines. “Mindlines [should] reflect not collective folly, nor coercive scientism but communal wisdom” (Gabbay & Le May, 2010, p. 203).
Analyzing this professional discourse within chiropractic enables us to see who is participating and who is not; what is being stated and what is left unstated. As Cheek (2004) notes, CDA is a useful methodology to use in recognizing “the constraining effect of a particular discursive frame’s dominance which then creates the possibility of a space to be opened up for other discourses or ways of thinking” (p. 1143). What emerges from the interpretation of available texts in the discourse amongst chiropractors is that a rhetoric-filled, one-sided conversation that is heavily weighted toward science-oriented reform is not conducive to real interaction. It is the hope that by bringing these underlying ideological power struggles to light, that a more participatory dialog can commence with more representation by everyday chiropractors and subluxation-based chiropractors (who may not be one in the same group) whose livelihoods will be impacted by implementing the policy decisions and institutional practices (e.g., scope of practice laws, insurance reimbursement, requirements for licensure and its renewal, etc.) that are currently being decided by academic chiropractors and the back/neck/pain specialist segment (who may not be one in the same group) who will not, themselves, be held accountable to these same standards.
Acknowledgments
The author wishes to thank Mike Musselman and Nicole Minatrea for their assistance in locating several of the articles used as data in this research. Additionally, the revisions made to the manuscript by Heather Emory and the constructive suggestions for revision from anonymous reviewers and the editor are greatly appreciated.
REFERENCES:
Abbott, A. (1988).
The system of professions: An essay on the division of expert labor.
Chicago: University of Chicago Press.Allen, D. (2000).
Doing occupational demarcation:
the ‘boundary-work’ of nurse managers in a district general hospital.
Journal of Contemporary Ethnography, 29, 326–356.Baer, H. (1996).
Practice-building seminars in chiropractic:
a petit bourgeois response to biomedical domination.
Medical Anthropology Quarterly, 10, 29–44.Branson, R. (2009).
Hospital-Based Chiropractic Integration Within a Large
Private Hospital System in Minnesota: A 10-Year Example
J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 740–748Briggance, B. (2005).
A Proposal Regarding the Identity of Chiropractic: Embrace the Centrality of the Spine
Journal of Chiropractic Humanities 2005 (Jun 13); 12: 8-15Bucher, R., & Strauss, A. (1961).
Professions in process.
American Journal of Sociology, 66, 325–334.Cant, S., & Sharma, U. (1996).
Demarcation and transformation within homoeopathic knowledge.
A strategy of professionalization.
Social Science & Medicine, 42, 579–588.Carter, R. (2005).
Chiropractors struggle with change.
Journal of the Canadian Chiropractic Association, 49, 9–12.Cheek, J. (2004).
At the margins? Discourse analysis and qualitative research.
Qualitative Health Research, 14, 1140–1150.Chestnut, J. (2008 February 6).
Designing, conducting and publishing research within the chiropractic wellness paradigm – part 2.
Journal of Vertebral Subluxation Research.
Retrieved from. http://www.jvsr.com/1487/2008-1040_valid.pdfChiropractic Board of Australia. (2011 January 28).
Codes and guidelines.
Retrieved from. http://www.chiropracticboard.gov.au/codes-and-guidelines.aspxClum, G. (2010 September 1).
A discussion of a limited number of changes in the CCE’s 2007 version of the Standards
for Doctor of Chiropractic programs and proposed revisions to the same.
Retrieved from. http://www.lifewest.edu/pdfs/CCE%20revision%20concerns%209%201%2010.pdfCollins, P. H. (1986).
Learning from the outsider within: the sociological significance of black feminist thought.
Social Problems, 33, S14–S32.Dehen, M., Whalen,W., Farabaugh, R., & Hawk, C. (2010).
Consensus Terminology for Stages of Care: Acute, Chronic, Recurrent, and Wellness
J Manipulative Physiol Ther 2010 (Jul); 31 (9): 651–658Dengele, N. (2005).
On the margins of everything: doing, performing and staging science in homeopathy.
Science, Technology and Human Values, 30, 111–136.Duenas, R., Carucci, G., Funk, M., & Gurney, M. (2003).
Chiropractic–primary Care, Neuromusculoskeletal Care, or Musculoskeletal Care?
Results of a Survey of Chiropractic College Presidents, Chiropractic Organization Leaders,
and Connecticut-licensed Doctors of Chiropractic
J Manipulative Physiol Ther 2003 (Oct); 26 (8): 510–523Fairclough, N. (1992).
Discourse and social change.
Cambridge: Polity.Fairclough, N. (1995).
Critical discourse analysis.
London: Longman.Fairclough, N. (2003).
Analyzing discourse: Textual analysis for social research.
London: Routledge.Feise, R. (2005).
Further decline in chiropractic popularity projected.
Journal of the American Chiropractic Association, 42, 19–22.Filippi, M. (2005 July 12).
Chiropractic unmasked: how shame and self loathing are driving DC’s into extinction.
Journal of Vertebral Subluxation Research, .
Retrieved from. http://www.jvsr.com/index.asp%3D265.Finlay, L. (1998).
Reflexivity: an essential component for all research?
British Journal of Occupational Therapy, 61, 453–456.Finlay, L. (2002).
“Outing” the researcher: the provenance, process and practice of reflexivity.
Qualitative Health Research, 12, 531–545.Fournier, V. (2001).
Amateurism, quackery and professional conduct: the constitution of ‘proper’ aromatherapy practice.
In M. Dent, & S. Whitehead (Eds.),
Managing professional identities: Knowledge, performativity and the ‘new’ professional
(pp. 116–137). London: Routledge.Frank, R. (2002).
Integrating homeopathy and biomedicine: medical practice and knowledge production among
German homeopathic physicians.
Sociology of Health and Illness, 24, 796–819.Freidson, E. (1970).
Professional dominance: The social structure of medical care.
New York: Atherton Press.Gabbay, J., & Le May, A. (2010).
Practice-based evidence for health care: Clinical mindlines.
London: Routledge.Gatterman, M. (2006).
The patient-centred paradigm: a model for chiropractic health promotion and wellness.
Chiropractic Journal of Australia, 36, 92–96.General Chiropractic Counsel. (2004).
Consulting the profession: A survey of UK chiropractors, 2004.
Retrieved from. http://www.gcc-uk.org/files/link_file/ConsultTheProfession.pdfGeneral Chiropractic Counsel. (2010 August 18).
Guidance on claims made for the chiropractic vertebral subluxation complex.
Retrieved from.
http://www.gcc-uk.org/files/link_file/Guidance_on_claims_made_for_the_chiropractic_VSC_18August10.pdfGieryn, T. (1983).
Boundary-work and the demarcation of science from non-science:
strains and interests in professional ideologies of scientists.
American Sociological Review, 48, 781–795.Gleberzon, B., Cooperstein, R., & Perle, S. (2005).
Can chiropractic survive its chimerical nature?
Journal of the Canadian Chiropractic Association, 49, 69–73.Good, C. (2004).
The Subluxation Syndrome: A Condition Whose Time Has Come?
J Chiropractic Humanities 2004; 11: 38–43Good, C. (2010a ).
A criticism of an epidemiological examination of the subluxation construct using Hill’s criteria
of causation: limitations, suspect conclusions and an opportunity missed.
Chiropractic and Osteopathy, 17. doi:10.1186/1746-1340-17-13.Good, C. (2010b).
The Great Subluxation Debate: A Centrist's Perspective
J Chiropractic Humanities 2010 (Jun); 17 (1): 33–39Greenawalt, K. (2004, July 29).
Our profession needs an identity.
Dynamic Chiropractic, 16, 20.Habermas, J. (1990).
Discourse ethics:
notes on a program of philosophical justification Moral consciousness and communicative action.
Cambridge: MIT Press.Hafferty, F., & Light, D. (1995).
Professional dynamics and the changing nature of medical work.
Journal of Health and Social Behavior, 132e153, extra issue.Halpern, S. (1992).
Dynamics of professional control: internal coalitions and crossprofessional boundaries.
American Journal of Sociology, 97, 994–1021.Haneline, M. (2005).
What is evidence?
Journal of the American Chiropractic Association, 42, 15–19.Harding, S. (1998).
Is science multicultural? Postcolonialisms, feminisms and epistemologies.
Bloomington: University of Indiana Press.Haug, M., & Lavin, B. (1983).
Consumerism in medicine: Challenging physician authority.
Beverly Hills: Sage.Hawk, C. (2004).
Evidence of chiropractors’ views on identity: who do we think we are?
American Journal of Chiropractic, 41, 45–50.Hollenberg, D., & Muzzin, L. (2010).
Epistemological challenges to integrative medicine:
an anti-colonial perspective on the combination of complementary/CAM with biomedicine.
Health Sociology Review, 19, 34–56.Hyland, J., & Baird, R. (14 August 2005).
Dynamic chiropractic. 34–35.Johnson, C., Baird, R., Dougherty, P., Globe, G., Green, B., Haneline, M., et al. (2008).
Chiropractic and public health: current state and future vision.
Journal of Manipulative and Physiological Therapeutics, 31, 397–410.Kamler, B. (1997).
An interview with Terry Threadgold on critical discourse analysis.
Discourse: Studies in the Cultural Politics of Education, 18, 437–451.Kaptchuk, T., & Eisenberg, D. (1998).
Chiropractic Origins, Controversies, and Contributions
Archives of Internal Medicine 1998 (Nov 9); 158 (20): 2215-2224J Keating, K Charton, J Grod, S Perle, D Sikorski, J Winterstein
Subluxation: Dogma or Science?
Chiropractic & Osteopathy 2005 (Aug 10); 13: 17Keating, J., Green, B., & Johnson, C. (1995).
‘Research’ and ‘science’ in the first half of the chiropractic century.
Journal of Manipulative and Physiological Therapeutics, 18, 357–378.Kent, C. (2009 November 18).
Chiropractic: a glorious future.
Dynamic Chiropractic, 28–31.Kisinger, F. (2009).
Beneficence and the professional’s moral imperative.
Journal of Chiropractic Humanities, 16, 44–46.Lawrence, D., & Meeker,W. (2006).
Commentary: the national workshop to develop the chiropractic research agenda:
10 years on, a new set of white papers.
Journal of Manipulative and Physiological Therapeutics, 29, 690–694, 24.Lehman, J., & Suozzi, P. (2008).
Founding integrative medicine centers of excellence:
one strategy for chiropractic medicine to build higher cultural authority.
The Journal of Chiropractic Education, 22, 29–33.Luke, A. (2002).
Beyond science and ideology critique: developments in critical discourse analysis.
Annual Review of Applied Linguistics, 22, 96–110.McDonald W.P., Durkin K.F., Pfefer M.
How Chiropractors Think and Practice: The Survey of North American Chiropractors
Semin Integr Med 2004; 2: 92–98Meeker, W., & Haldeman, S. (2002).
Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine
Annals of Internal Medicine 2002 (Feb 5); 136 (3): 216–227Mills, S. (2004).
Discourse.
London: Routledge.Mootz, R. (2001).
Professional identity: the role of chiropractic theory.
Topics in Clinical Chiropractic, 8, 1–8.Mootz, R. (2007).
Chiropractic’s current state: impacts for the future.
Journal of Manipulative and Physiological Therapeutics, 30, 1–3.Morgan, L. (2005).
Is chiropractic a CAM therapy or is it a separate profession?
Journal of the Canadian Chiropractic Association, 49, 133–136.Murphy, D., Schneider, M., Seaman, D., Perle, S., & Nelson, C. (2008).
How Can Chiropractic Become a Respected Mainstream Profession?
The Example of Podiatry
Chiropractic & Osteopathy 2008 (Aug 29); 16: 10Nelson, C. (1997).
The subluxation question.
Journal of Chiropractic Humanities, 7, 46–55.Nelson, C., Lawrence, D., Triano, J., Bronfort, G., Perle, S., Metz, R. D., et al.
Chiropractic As Spine Care: A Model For The Profession
Chiropractic & Osteopathy 2005 (Jul 6); 13: 9Parsons, T. (1951).
The social system.
New York: Free Press.Pelletier, K., & Astin, J. (2002).
Integration and reimbursement of complementary and alternative medicine by managed care
and insurance providers: 2000 update and cohort analysis.
Alternative Therapies in Health and Medicine, 8, 38–39, 42, 44.Pescosolido, B. (2006).
Professional dominance and the limits of erosion.
Society, 43, 21–29.Pescosolido, B., Tuch, S., & Martin, J. (2001).
The profession of medicine and the public: examining Americans’ changing confidence in physician authority
from the beginning of the ‘health care crisis’ to the era of health care reform.
Journal of Health and Social Behavior, 42, 1–16.Phillips, R. (2004).
The battle for innate: a perspective on fundamentalism in chiropractic.
Journal of Chiropractic Humanities, 11, 2–10.Redwood, D., Hawk, C., Cambron, J., Vinjamury, S. P., & Bedard, J. (2008).
Do Chiropractors Identify with Complementary and Alternative Medicine?
Results of a Survey
J Altern Complement Med. 2008 (May); 14 (4): 361–368Rehm, W. S. (1986).
Legally defensible: chiropractic in the courtroom and after, 1907.
Chiropractic History, 6, 50–55.Riggs, J. (2007 August 13).
Spinal health specialist? Oh my!
Dynamic Chiropractic, 48–49.Robbins, B. (1992).
Secular vocations: Intellectuals, professionalism, culture.
London: Verso.Rosner, A. (2005 June 4).
Identity Crisis: A Profession at the Crossroads
Dynamic Chiropractic – June 4, 2005; 23 (12): 42–44Shore, C., & Wright, S. (1999).
Audit culture and anthropology: neo-liberalism in British higher education.
Journal of the Royal Anthropological Institute, 5, 557–575.Smith, J. (2007).
Critical discourse analysis for nursing research.
Nursing Inquiry, 14, 60–70.Smith, M., & Carber, L. (2009).
Survey of US chiropractors’ perceptions about their clinical role as specialist or generalist.
Journal of Chiropractic Humanities, 16, 21–25.Sportelli, L. (2005 May 21).
No Identity = Bankruptcy
Dynamic Chiropractic – May 21, 2005; 23 (11): 26Sportelli, L. (2006).
Commentary: what identity for chiropractic?
Chiropractic Journal of Australia, 36, 76–79.Starr, P. (1984).
The social transformation of American medicine.
New York: Basic Books.Tang, S. (2006).
From outcast to inboard’:
the transmission, professionalization and integration of acupuncture Into British medical culture.
Asian Medicine, 2, 254–276.Tataryn, D. (2002).
Paradigms of health and disease: a framework for classifying and understanding
complementary and alternative medicine.
The Journal of Alternative and Complementary Medicine, 8, 877–892.Taylor, D. (2006).
Health care industry shaping chiropractic’s future.
Journal of the American Chiropractic Association, 43, 19e23.Triano, J., Goertz, C., Weeks, J., Murphy, D., Kranz, K., McClelland, G., et al. (2010).
Chiropractic in North America: toward a strategic plan for professional renewal-outcomes
from the 2006 chiropractic strategic planning conference.
Journal of Manipulative and Physiological Therapeutics, 395–405.Villanueva-Russell, Y. (2005).
Evidence-based medicine and its implications for the profession of chiropractic.
Social Science & Medicine, 60, 545–561.Villanueva-Russell, Y. (2009).
Chiropractors as folk devils: published and unpublished coverage of a moral panic.
Deviant Behavior, 30, 175–200.Wardwell, W. (1994).
Alternative medicine in the United States.
Social Science & Medicine, 38, 1061–1068.Wardwell,W. (1996).
Chiropractic’s unique evolution and its future status.
Journal of the Canadian Chiropractic Association, 40, 34–39.Warnock, S. (2005).
The optometrist’s rise to power in the health care market, or ‘it’s optometric physician, to you.
Science Communication, 27, 100–126.Welsh, S., Kelner, M., Wellman, B., & Boon, H. (2004).
Moving forward? Complementary and alternative practitioners seeking self-regulation.
Sociology of Health and Illness, 26, 216–241.Willis, E. (2006).
Introduction: taking stock of medical dominance.
Health Sociology Review, 15, 421–431.Winterstein, J. (2002).
Intraprofessional concerns.
Journal of Chiropractic Medicine, 1, 171–174.Winterstein, J., Phillips, R., & Kremer, R. (2004 September 1).
To tier or not to tier chiropractic?
Dynamic Chiropractic, 18, 20, 36.Wolinsky, F. (1993).
The professional dominance, deprofessionalizatoin, proletarianization and corporatization perspective:
an overview and synthesis. In F. Hafferty, & J. Mckinlay (Eds.),
The changing medical profession (pp. 11–24).
New York: Oxford University Press.World Federation of Chiropractic. (2005).
P. Carey, G. Clum, P. Dixon,
The Identity of the Chiropractic Profession
Final Report of the Identity Consultation Task Force
World Federation of Chiropractic, Ontario, Canada, 2005Yoshida, M. (2002).
A theoretical model of biomedical professionals’ legitimisation of alternative therapies.
Complementary Health Practice Review, 7, 187–208.Young, J. H. (1998).
The development of the office of alternative medicine in the national institutes of health, 1991–1996.
Bulletin of the History of Medicine, 72, 279–298.
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