Transformation or Plug and Play?

Shifting roles, relationships, marketplace positions and economics have every aspect of health care under strain. A leading observer, leader and chronicler of integrative health care for decades named John Weeks recently wrote a perceptive piece on his analysis of the opportunities for doctors of naturopathic medicine (NDs) in this challenging landscape. Can we learn something from his analysis that might affect chiropractic? I believe so.

Weeks’ piece focused on Doctors of Naturopathy (Naturopathic doctors, Naturopathic Medical Physicians), a profession with its roots, trunk and branches intertwined with chiropractic in many respects. Both began within a few years of each other; both are historically grounded in neo-vitalistic principles; both have been vilified and attacked by political medicine; and the training and clinical applications of both overlap in many respects. Chiropractic grew and established itself through the twentieth century; naturopathy flourished early, shrank until the late 1970s and then began to recover, organize and ultimately establish accredited educational requirements as a basis for growth.

Despite a largely shared philosophic paradigm on innately driven health and healing, the professions can often diverge in clinical focus. While both have historically been health system outsiders or consigned to ‘affinity benefit’ add-ons, NDs’ collective sense of their marketplace position has shifted substantially over the last decade while chiropractic’s has largely remained the same. Naturopathy’s leadership has moved to establish a position that is now more aligned with Western medicine than chiropractic in key ways, while still attempting to retain its ‘historic soul’ as a natural healing art and science. NDs are making steady inroads in regulation and licensure, giving them increased scope of practice laws now in 20 states with the ability in a few to perform new procedures (obstetric, limited prescription and minor surgery) with additional training or medical supervision. And they have achieved this in the face of often potent political opposition, successfully proving safety, efficacy and an ability to somewhat co-opt medical doctors’ opinions of the profession–especially as Millennial medical students become doctors. There have been political challenges between the two professions at times, but both now generally enjoy a healthier relationship.

Weeks points out that, with or despite all this that perhaps the naturopathic profession’s greatest opportunity shouldn’t be viewed as a clinical role but as a larger one of facilitating transformation. He argues that by treating the profession’s fundamental philosophy as a set of policy principles and seeking broad adoption of them by other clinical and non-clinical stakeholders, they can become change agents–transformers, building on what I venture to sum up as a description of their strategy: ‘alignment based on safety; separation based on distinction.’ Using this, they’ve often lowered the temperature of debates about their legitimacy. Change agency is thought leadership. Does Naturopathy have the potential to redefine medicine? Don’t be too quick to dismiss the possibility.

Given all this, what might we learn from all this as doctors of chiropractic?

While Chiropractic’s practices have been transformational for patients, the same cannot be said for its influence on health systems. In its early days first attacked, then marginalized and ostracized, then grudgingly incorporated but constrained, managed and controlled, chiropractic has always been bifurcated but now is close to a split. One segment hews to the profession’s philosophic DNA and eschews participation on terms defined by health systems; the other has steadily revised its clinical role by permitting its practices to be molded by metrics external to the profession’s own paradigm (managed services based on symptomatic relief, economics based on minimal compensation rather than outcomes, short term function rather than long term health, etc.). Both segments are capable of notable and important contributions to population health, and both suffer consequences from the marketplace positions created by their choices. Those committed to subluxation correction and a philosophic compass cannot fit into health system processes and metrics, while those who have accepted the reductionistic paradigm of evidence-based criteria find their role and practices more and more constrained (or celebrated, depending on your view) to palliative care, and outcomes measured in terms of symptoms and subjective function.

The effects of all this are still to be played out, but health care trends are beginning to mold the marketplace in new ways. As increasing numbers of Americans are pushed into the new role of health care consumers with high deductibles who must pay out of pocket for a great deal of care, the ‘historic’ segment of the profession will be challenged to make its case more and more directly to consumers: there will simply be more ‘clutter’ to cut through, not less. The marketplace challenge will be that thriving with a position based on an identity drawn in sharp relief from Western medicine will likely require new ways to reach, engage and keep consumers; further, it’s likely that new outcomes models will be needed as decision support tools grow more sophisticated.

In contrast, for the ‘complementary’ segment to thrive, a role focused on palliative care and subjectively evaluated function will place its members essentially in competition with other professions who claim similar territory and expertise. Physical and occupational therapists, physicians assistants, and others already established with a halo of medicine’s cultural authority have the advantage of simply being ‘less different.’ In the face of increasing competition for same or similar therapeutic services, why will consumers choose doctors of chiropractic? Different considerations will segment consumers as well: some are likely to find one segment’s identity appealing as an alternative, while others are likely to seek the other segment because its identity is complementary and embedded in health systems and operations.

Naturopathy has made its strategic bed and is happily buying sheets; Chiropractic is trying to have two beds, and we’re arguing over where we want to sleep. It’s not enough to view our internecine conflict as one that results in winners and losers: arguing over the placement of deck chairs and ignoring the iceberg doesn’t turn out well for anyone. The health care marketplace is likely to be much less forgiving to our conflicted identity than managed care has ever been, and unless the chiropractic profession develops some accord around one role, the other or a synthetic description both segments can live with, it’s very possible that consumers will vote with their feet and leave us behind.

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