Chiropractic: Subtract Drugs, Don’t Add Them

A recent personal health crisis brought a practical example of the role of chiropractic into sharp focus. As passions heat up over the contentious issue of scope expansion and prescription privileges, and with no real information about what health care consumer/patients actually want, anyone who has an opinion about the issue is making a lot of value-based assumptions. With that in mind, and with the historic and inclusive ACC Paradigm of Chiropractic as a starting point, here’s one man’s story and some potential insights for the profession.

Hospitalized for an inflamed gall bladder in August of this year, incidental findings revealed an often-paired set of genetic anomalies: a bicuspid aortic valve and badly dilated ascending aortic root. After multiple consultations, more tests and a lot of consideration, both were scheduled to be replaced at the end of October. The surgery went fine, but a lot of additional attention was paid to the awareness that (presumably) under the stress of surgery, my heart has tended to go into (asymptomatic) atrial fibrillation.

Atrial fibrillation is a serious, often life-threatening condition of asynchronous chamber contraction. It increases the chance for clot formation, valvular insufficiency, etc. The three classes of anti-arrhythmic drugs are prescribed in a global marketplace that is of staggering size: a Global Data forecast report sees the market going from $4.6bn in 2013 to $5.7bn by 2023. The US share of the market was 59% in 2013, forecast to be 42% in 2023. I have now been put on the main anti-arrhythmic Amiodarone twice after surgeries which permitted conversion to a normal sinus rhythm. I’m personally grateful for its action.

But I’m also aware that I didn’t do what needed to be done prior to surgery: I didn’t ensure that a chiropractic examination and treatment would help optimize the function of my parasympathetic nervous system–required for sympathetic inhibition–and I knew my back was out. Some will wonder why that matters. The answer goes back to basic neurophysiology: the parasympathetics need to be able to function to inhibit sympathetic responses. I’d planned on it, but the complicated planning for family needs displaced it. Bad on me.

So the insight about our profession in all this came out of a conversation I had with a cardiac electrophysiologist several days post-surgery. I was in atrial fibrillation, and he stopped by to help weigh and consider the different options. After he was done, I spoke up.

“Well,” I said, “all that makes sense. But I’m a chiropractor, and my clinical paradigm is one of optimal neurologic function. And what I don’t know is how well my own parasympathetics are able to be involved in helping my body’s own innate intelligence mediate a response to the profound insult surgery creates for my body.” I detailed why I thought that was possible: my own poor pre-surgical planning. I braced myself for anything from a terse, polite acknowledgement of my concerns to outright dismissiveness of my perspective. What came back, though, shocked me.

“Oh,” he answered respectfully. “I totally agree. As a matter of fact, what we don’t know is how to best prepare someone for the stress of these kinds of surgery. What you say makes absolute sense, and as a matter of fact, I can draw even further parallels.” He–a medical doctor–then detailed a ‘bigger tent,’ drug/drugless approach inclusive of both medicine and chiropractic to these kind of very common problems in medical practices. I was stunned: I’d just been lectured about the power of chiropractic in more articulate terms than I’ve heard from most of my profession over the last thirty five years. We talked about additional implications for areas serviced by the vagus nerve, etc. Summation and the potential value of the chiropractic adjustment was something that made absolute sense to him.

The experience left me with two areas of certainty: that we have wasted a lot of time asking many research questions that have not clarified our value, but in fact diffused it, reduced it and permitted people to think of chiropractic as a therapy instead of a paradigm. And the second is that (based on other examinations of lowered pain-killer costs, among others), if adequately formed and studied, an evaluation of chiropractic practices that optimize autonomic nervous system function and balance would be likely to reveal worldwide savings on drug costs that would be in the billions of dollars. The difference is whether or not we’re a therapy or a paradigm. As a therapy, our contribution can be studied in isolation and contrasted with competing approaches. As a paradigm, we stand alone.

It’s important to contrast this kind of opportunity with what seems to me a ridiculously immature conception of a doctor of chiropractic as a source of limited drug prescription rights. As a profession, it seems much clearer to me that we should be exploring how best to reduce the use of drugs, not facilitate their distribution. And, rather than seeking to be on an ‘integrative’ clinical team in a hospital setting where we are a therapy (with competitors down the hall in PT/OT), we should instead clarify a role of a contravening and balancing paradigm. Why wouldn’t we work hard on integrative models that create distinction and clarify our important role instead of diffusing it?

So: one man’s story. Some will read this and say, ‘but we don’t know for sure that it would help.’ And that’s true: right now we don’t. But that’s part of our problem, and food for thought about the direction of the profession. If our role is to optimize neurologic function, why wouldn’t a corollary systems approach also be to optimize health system function? A drug- and surgery-based paradigm is helpful for many; I’m sitting here as proof of that. But a drugless alternative is potentially a game changer (how much might be saved?), and we’re arguing amongst ourselves over whether or not we should be able to add to the problem instead of improving it.

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5 Responses to Chiropractic: Subtract Drugs, Don’t Add Them

  1. Rob Scott says:

    As usual Dr. Bolles, a well thought out and articulate quandary.
    Thanks and glad your procedure was a success.

  2. Jeffrey Johnson says:

    Thank you for all your effort into the area of the future of chiropractic. I am a regular reader of your blog. I hope your recovery is going well.

    Although I understand the appeal of being completely unique in the marketplace, my concern is that if the role of optimizing neurologic function is marketed to the public as our main focus, we will be left with very few, if any, new patients. Right now, the vast majority of chiropractic patients seek us out for back pain/spinal problems. It would seem that expanding upon being “spinal experts”, not just back pain therapists, would further increase chiropractic patients, while going in a different direction would confuse the public even more.

    Right now, there is no market for optimizing neurologic function. By the time we can teach the public about this, educate the medical community, and do more research on it, all our patients might be have already decided to go to another provider group for spinal problems. It would seem that if we brand this focus as “wellness”, we would have even more competition than we would for pain relief, including proven and free self-measures like exercise.

    It would be great if we could brand the profession as “neurology optimization.” I’m just not sure it is possible.

    Maybe a future article could discuss your thoughts on how we might brand this for marketing purposes to the public, while trying also to keep the back pain patients that we have now.

    Thanks again,

    jj

    • Stephen Bolles says:

      Dr. Johnson, thanks for the important question you raised about how, essentially, to position the profession when a technical description of our paradigm doesn’t seem marketable. Do we follow the money? Do we hew rigidly to dogma? Or is there a third, bridging strategy that preserves the integrity of the chiropractic paradigm and carves out a role based on distinction, rather than sameness?
      The profession missed an immense opportunity to ‘own’ the concept of wellness, well-defined by the Institute for Alternative Futures back in 1998. Now everyone owns wellness, and while important it’s as indistinct a concept as can be. As a profession we know that optimal neurologic function is fundamental to everything–especially health and wellness–and so our contributions to the field of wellness can, and should be, very well defined. But not based on what someone else can do.
      Should we be pain doctors? Prospective patients seek DCs out for pain relief for two basic reasons: first, the ability to relieve pain by applying the chiropractic paradigm has always been an important professional contribution, even if it’s often misleading as evidence of clinical improvement. Second, we accepted a therapeutic role in managed care, because pain is validated, trans-professional metric. And frankly, we were hungry–even desperate–to become part of the system. We just didn’t read the fine print.
      But as we know, patients’ subjective awareness only tells part of the story. I’m not saying we shouldn’t respond to consumer/patients’ interest in pain relief. What I am suggesting is that if we bind ourselves into that professional definition, we become a therapy, not an entirely distinct way of approaching health and healing. Rather than ‘pick me! Pick me!’ we should be saying, ‘Chiropractors offer a unique path to pain relief through optimal function. Now let’s talk about what that means.’
      Now, no one really knows the answer to what the marketplace wants from chiropractors because we haven’t asked it. Honestly, we’re all guessing until we do. And because the public’s perceptions are so steeped in mechanistic medicine we’re probably in a position, I think, of echoing what Steve Jobs famously said: the public doesn’t know what it wants.
      So what I’m suggesting–echoing many others; this is certainly not my idea–is that there is ample room in the health care marketplace for a profession that offers a truly alternative perspective (paradigm) on health and healing. If we think we are going to fulfill a gap in the US health care primary workforce based on emulating medicine, it’s my very strong view we’re kidding ourselves. Rather, we should be working on intraprofessional accord, embrace the diversity of expression our profession apparently thrives on, and seek to work alongside our medical brethren, but not trying to be one of them. A scrip pad in our pocket is not going to help.

      • Jeffrey Johnson says:

        Thank you for the well-crafted response Dr. Bolles. I will ponder this further and I look forward to your articles, as this is one of my favorite topics.

  3. Dr. Gilles LaMarche says:

    Brilliant insight Dr. Bolles. Glad to know you are recovering well.

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