The ability of medicine to achieve cultural authority in the early 1900s was a “confluence of factors encompassing professionalism, the Industrial Age and an incentive-skewed market.” (1) What may be most remarkable, given the almost exponential growth of health care costs through the 20th century, was the duration that medical cultural authority went unchecked. Medicine was said to have achieved “professional sovereignty.” Over extending its reach to protect self interest, medicine squandered its public trust, encouraging the managed care movement and losing authority along the way. The relevance for the chiropractic profession is that cultural authority is defined by society through its structural operations and is granted to professions to the extent that trust is earned.
Cultural authority may best be defined as the accumulation of public trust that warrants the progressive granting or relative autonomy and ability to self-regulate based upon the demonstration of legitimacy and competency by a professional group. Once achieved, cultural authority allows a profession, through its body of abstract knowledge, to define its own professional truth. The profession decides what is fact and what is fiction and the public accepts the rules set forth. Cultural authority is characteristically unique in “having authority without having to overtly exercise it” as opposed to social authority, which is the ability to command people. The two primary features of cultural authority, competency and legitimacy must be achieved collectively as a group. While individuals may acquire local reputation, it is the profession’s aggregate which conveys meaningful warrant of trust and authority. Competency is the exercise of advanced abstract knowledge in the demonstration of technical expertise. Legitimacy is achieved through the competent advance of public health.
If we can agree that achieving cultural authority is in the best interests of the chiropractic profession and the public we serve, then what steps can be taken to enhance cultural authority? By the collective efforts of the profession as a whole, the following recommendations by Enzman to medical profession also serve the chiropractic profession:
- Continually demonstrate competency to the public; proof of training and licensing is no longer sufficient
- Provide ‘credible data’ to validate medical claims and recommendations
- Focus upon outcome analysis, a ‘crucial’ factor for the medical profession
- Standardization of practice patterns, both regionally and within each specialty
- Standardize the lexicon, which demonstrate peer validation of competency
- Focus upon the societal value of health, not upon reimbursement
- Avoid ‘filtering and restricting information available to patients’; embrace the informed consumer(patient)
- Be leaders and therefore, be honest, at all times
A course of action from a consensus conference held in 2005 and 2006 in Chicago, IL with leaders of the profession from practice, academia, research and politics (2) can be seen to build on these foundations. A partial list to place the chiropractic profession on the road towards cultural authority includes:
- Standardize the training of chiropractors using principles of science, best available evidence, and consensus. Consensus must be based upon the previous two attributes.
- Raise the standards for admission to and graduation from chiropractic colleges, and raise the standards for licensing
- Standardize the chiropractic lexicon
- Affiliate chiropractic colleges with established and proven universities so that resources (faculty, research facilities, etc.) can be shared
- Define the most fundamental aspects of chiropractic care: subluxation (in a quantifiable, testable manner); treatment frequency and duration for given clinical presentations;
- Standardize clinical outcome measures to validate responses to chiropractic care (“credible data”)
- Increase funding towards chiropractic research
- Encourage attendance at research symposiums
- Professional unity: one primary organization to represent the profession politically; all chiropractic colleges embrace and implement collectively determined standards of care;
- Patient centered, evidence based care is the foundation for training of chiropractors
- Reduce variation of approaches to diagnosis and treatment within the profession
- Increase training in all manner of public health issues for chiropractors
- Encourage chiropractors to become involved with American Public Health Association
These measures recognize that there are only 5 domains through which a profession can wield sufficient leverage to influence the social awareness. They are: education, research, regulation, workplace, leadership. The most widespread domain is through the chiropractic workplace where the attitudes and judgments of individual patients are influenced every day by the behaviors and skills of the practitioners they encounter.
The abstract knowledge most cohesive and widely appreciated by the public chiropractic serves is that of nonsurgical spine specialist role. “As recent events have shown, consistent with the history of how professions do or do not grow, the acquisition of each benchmark results in broader access to supportive resources and policy.” (2) By exercising a clear focused identity, working with the public understanding and not against it, by collectively working towards achievements in education, research, regulation and leadership, the ability of the chiropractic profession to define its own professional truth is in our future.
What can you do as an individual health care provider?
Each individual chiropractor can assist in the process of the collective advancement of cultural authority by following some key action steps:
- Review the National Committee for Quality Assurance Back Pain Recognition Program for physicians (www.ncqa.org/BPRP) and consider participating. This program offers a ‘level playing field’ to all spine-care providers with identical standards for all disciplines. The process of NCQA participation reinforces a patient centered, evidence based approach to evaluation and care.
- Utilize peer reviewed educational literature for your patients.
- Regularly attend clinical research symposia such as the American Chiropractic College-Research Agenda Conference, World Federation of Chiropractic Conference, North American Spine Society, American Pain Society, American Public Health Association.
- Implement clinical best practices, for example, as in the recommendations of the CCGPP (council on chiropractic guidelines and practice parameters clinicalcompass.org).
- Join and advocate in support of the American Chiropractic Association efforts to modernize regulation and education current with best practices.
- Enzman D. Surviving In Healthcare 2007. Mosby.
- Triano J, Goertz C, Weeks J, Murphy D, Kranz K, McClelland G, Kopansky-Giles D, Morgan W, Nelson C. Chiropractic in North America: Toward a strategic plan for professional renewal – outcomes from the 2006 strategic planning conference. J Manipulative Physiol Ther 2010;