From: 2/03/01 Sigmund Miller, DC - Editor ChiroView Presents www.ChiroViewPresents.com Dr. Adrian Wenban, from Barcelona Spain, one of CVP's Philosophy of Chiropractic department heads submitted an article entitled "Identity and Integrity" which I broadcasted last week. His initial article got your "juices going" and resulted in about 2000 responses from the more than 18,400 chiropractors receiving this CVP broadcast. If you missed it, just click http://www.chiroviewpresents.com/faq2/39.4.htm Dr. James Winterstein, President of National University of Health Sciences responded. Dr. Wenban and Dr. Winterstein responded once more to each other. Their cyber-dialogue was so enjoyable and provocative that I requested, and they kindly granted, me permission to broadcast their comments in its entirety. On a personal note, this is the second time Jim responded to an article broadcasted by CVP. This type of "back and forth dialogue" is what I enjoy most and what was my primary reason for launching CVP 1 1/2 years ago. As I've suggested previously, members of this extraordinary profession can hold differing opinions and not differ in principle. I look forward to your comments. Enjoy! Sigmund Miller, DC - Editor ChiroView Presents www.ChiroViewPresents.com Chiroclinix.com - Director of Community Relations www.Chiroclinix.com Note: This broadcast is going out to 18,000+ chiropractors representing 16 countries. You are receiving CVP broadcasts because you either subscribed via a form on our website, or you or someone you know requested your address be added to our subscription list. If you choose not to receive these weekly broadcasts, simply click reply and write "off". To gain access to the CVP site, you must obtain a username and password. Go to www.ChiroViewPresents.com and then click „subscribe¾. Dr. Winterstein responds to Dr. Wenban's article: Dear Sig, I am not sure how you handle the responses, but I do wish to make one to Dr. Wenban regarding his column on "philosophy." Dr. Wenban makes some fine observations and comments, and, I believe, some inaccurate assumptions. In particular, I am concerned that because a chiropractic degree program curriculum is very similar to an allopathic degree curriculum, he finds this to be "unfathomable and surely deleterious in the extreme to our separate and distinct identity." Whether we are allopathic students or chiropractic students or osteopathic students, each of whom might (and should) view the patient from a different perspective as far as health and healing are concerned, we still are all relating to human beings, who, while individual, surely share common physiological, anatomical, biochemical and pathological qualities. Were this not so, no text could ever have been written about any of these basic science studies. If, on the other hand, our clinical approach to the patient, including our thought processes regarding how to best help the patient as well as our methods of helping the patient were the same, then I would share some of his concerns. I also was somewhat nonplussed by the comment that "philosophy is a process of asking questions...." Philosophy is, at its root all about using the process (of asking questions as well as using other methods) to seek the TRUTH, to seek and gain WISDOM. In chiropractic, we have made "philosophy" a belief system for which, in large measure, we do not demonstrate the integrity of the application of good epistemology (a primary pillar of the philosophic quest). Calhoun has some fine points, but that does not mean that they represent the whole truth. Integrity, for example is much more than formulating and exemplifying one's own views. As far as I am concerned, integrity in this context would be much more accurately depicted as using a valid epistemologic method to discover whether or not that which I believe or hold as a view, is in fact true. If we simply accept the position of Calhoun, we can make the case that because Charles Manson held to his own views, he had integrity. Stephen Carter of Yale would certainly disagree. He makes a very strong case that integrity is about CHARACTER and implicit in this is the ability to make the hard decisions about right and wrong in behavior, and to determine whether what one believes is good and right and true. When it comes to chiropractic tenets, it is fine to believe them, but professional integrity also requires us to determine whether what we believe to be true really is true. Does, for example, a vertebral subluxate. If so, how do we objectively demonstrate this? If we can do that, we must ask the question, "does the spinal adjustment CORRECT the subluxated vertebra?" If it does indeed correct it, what effect does that have on the patient who is sick or well? It is exactly at this nexus that the person of real integrity must ask the tough questions, not demand the RIGHT to promote a view, because it belongs to the individual or the profession. I, for one, DO care what the scientific community thinks about what I, as a chiropractic physician do because in many ways they are the decision makers in the society in which I live (perhaps it is different is Spain). Here, those very people testify before the legislative bodies regarding health and healing and the legality and efficacy of the various methods of healing - the very same legislative bodies that determine whether or not I will have the privilege of practicing. Of what good is chiropractic, or my own capabilities to help people if I am not allowed to practice? This is not pandering, it is facing reality. I wish I had more time to proceed with this commentary but right now it is limited, so I must sign off. Please give my best to Dr. Wenban. Perhaps he will see fit to respond. James Winterstein, D. C. President - NUHS Reference: "The Insufficiency of Honesty; Stephen L. Carter: The Atlantic Monthly, February 1996: 74-76" Dr. Wenban Responds: Dear Dr. Winterstein, Thank you for taking the time to read, and respond to, my article titled "Identity & Integrity" which was distributed by ChiroViewPresents this last week. In the following reply I will focus on a couple of the points you raise, but leave a number of others for another reply which I will send early next week. You start your letter to me by stating, ".....I (Dr. Winterstein) am concerned that because a chiropractic degree program curriculum is very similar to an allopathic degree curriculum, he (Dr. Wenban) finds this to be "unfathomable and surely deleterious in the extreme to our separate and distinct identity." I would like to expand on why I find a medicalized "chiropractic degree program curriculum... deleterious in the extreme to our separate and distinct identity" by providing an example which I believe all to clearly exposes the consequences of medicalizing chiropractic undergraduate programs. This example pertains in particular to the medicalization of the Chiropractic undergraduate program at the National University of Health Sciences. My example, within the content of the following news report, speaks loudly of that which we should all fear most - The subtle seduction that is the giving up of our separate and distinct identity. This news report comes from the web site of ! the San Fernando Valley Chiropractic Society (http://members.aol.com/sfvcs/sfvcs.htm). I quote: „Chiropractic Medicine Gaining Primary Care Status" The above comes from the world wide web and was written by Howard Wolinsky (of The Serpent on the Staff authorship fame) for WebMD Medical News. The article appeared November 15, 1999. The bottom line of the article is an independent practice group in Illinois has agreed to have 17 DC's serve as primary care 'doctors' under a contract with Blue Cross Blue Shield of Illinois. The article begins as follows: Like any other primary care physician in HMO Illinois, the state's largest health care maintenance organization, Renee McMurry can perform gynecologic, breast and proctologic exams. She can do electrocardiograms. And when necessary, she can have her patients take antibiotics and other medications. But McMurry isn't like most primary care physicians. She's a DC, a doctor of chiropractic. Isn't it nice to know the year will end with chiropractic being recognized as the source for your proctologic exam and, of course, for your antibiotics to get you through the holidays! The IPA is known as Alternative Medicine Inc. (AMI) and has among its board of directors none other than the president of the National College. AMI thinks it is going to get primary care delivered as effectively and less expensively than from an MD. Dr. McMurry gets the citius, altius, fortius moment in her life--as she stated it to Mr. Wolinsky: "I almost equate this as having trained for the Olympics and finally being able to play." National gets their raison d'etre across: "Our graduates are well trained to be gatekeepers." The physician crowd of chiropractic gets fuel to go the extra mile and get prescription rights for schedule II drugs as is being advocated in Oklahoma. I believe there is, at worst, a contradiction, and at the least a system failure, in signing your name to a document (the ACC position paper #1. JMPT 1996;19:634) which clearly states that, "Chiropractic is....without the use of drugs and surgery" but then ending up with your graduates prescribing "antibiotics and other medications". However, it is my experience that this is not just a problem at the National University of Health Sciences, and it is not just a US chiropractic issue. Such incongruity between the values of our profession and the content and output of academic programs at chiropractic colleges is a pressing global issue for the chiropractic profession that we must rapidly, and collectively, confront. I believe that medicalizing the undergraduate education of chiropractors will ultimately eliminate the need for a chiropractic profession just as it is rapidly eliminating the need for an Osteopathic profession in the US (See NEJM 1999;341:1465-68.) I believe that medicalized chiropractic graduates are entering practice and offering the public "Nothing Unique" (spinal manipulation) and that such 'treatment' is being delivering from a model which is more akin to a Biomedical world view - "The diagnosis, treatment, rehabilitation and prophylaxis of pain syndromes......" (WFC definition of Chiropractic). In response to my ChiroView article you wrote, I quote, "Whether we are allopathic students or chiropractic students or osteopathic students, each of whom might (and should) view the patient from a different perspective as far as health and healing are concerned, we still are all relating to human beings, who, while individual, surely share common physiological, anatomical, biochemical and pathological qualities. Were this not so, no text could ever have been written about any of these basic science studies.¾ I agree with you that, "human beings, who, while individual, surely share common physiological, anatomical, biochemical and pathological qualities." What I do not agree with is: 1. Teaching chiropractic students in a way that more reflects the fundamental philosophical constructs to which Biomedicine ascribes. 2. I do not agree with having educators, trained in the basic sciences by the biomedical establishment, and having little knowledge of chiropractic, teach chiropractic students. 3. I do not agree with teaching chiropractic students more pathology, and as much microbiology, as medical students receive. By allowing what were cost saving educational necessities of the past to persist we are shooting ourselves, and our future, in the foot. My point is that we should be looking, and indeed teaching our students to look, at human beings through the unique pair of glasses offered by our fundamental philosophical constructs (Vitalism, Holism, Naturalism, Individualism, Conservative ethic, Professional Autonomy, Central Role of the Nervous system in Health). Focusing undergraduate students on MORE pathology, and as much microbiology, as medical undergraduates receive, does not empower those future chiropractors in the clinical encounter. Moreover, it does not prepare them to successfully survive and thrive in the real world as part of a separate and distinct profession. These issues must be confronted and resolved if our profession is to remain "Separate and Distinct". You, and 15 other college presidents, in signing the 1996 ACC document, agreed upon the importance of continuing to! , "foster a unique, distinct chiropractic profession.¾ I believe one of the greatest challenges to the future separate and distinct status of our profession has its genesis in the contradiction of teaching students that we are vitalistic whilst educating them to a view of the human body that is built on materialism. When a Rheumatologist looks at the human body, they do so from a certain perspective - through Rheumatologist colored glasses if you like. I would hope that we as chiropractors look at human beings, and their inseparable cultural milieu, through unique chiropractic tinted glasses. That tint should be colored by our fundamental philosophical principles, ie. "The body's innate recuperative power is affected and integrated through the nervous system"(Quoted from ACC Document that 16 college presidents signed). Teaching chiropractic students, in a small number of didactically presented philosophy classes, that their profession has its foundation in vitalism, and then having them spend their days studying more pathology than what medical students do, has dire consequences. I fear it leaves the chiropractic student conceptualizing the zygapophyseal joint, in isolation not just from the patients cultural milieu, but in isolation from the patient in total so that suddenly our hypothetical chiropractic student is on the slippery slope of reductionism. Why slippery? Because the incredible complexity inherent in living organisms precludes extrapolating up the hierarchical chain, and secondly, by having a medical focus (mechanistic), as opposed to a chiropractic focus (holistic) one quickly looses sight of the 'whole' living breathing human being before us - These two factors have in part given birth to the crisis we now see in Medicine. A crisis we should ensure does not infiltrate chiropra! ctic. I quote from a recent editorial in the Archives of Medical Research in relation to reductionism - "Reductionism has its limitations and does not allow for prediction from one hierarchical level to another. The most simple living organism is far to complicated to be understood by the study of its parts. It has many features that add up to much more than the sum of its constituents. it is now evident that living organisms are the most complex array of matter in the universe." (Arch Med Res 2000;31:1-2) Furthermore, just in case you doubt medicine is in crisis, I share with you the following - "Has Modern Medicine Hit a Brick Wall, And Is It's Future Uncertain?" That is the title of a recent editorial, from the editor, of the Medical Journal of Australia (2000;172:145). Martin B. Van Der Weyden, builds this editorial around a recently published book titled The Rise and Fall of Modern Medicine (Little Brown , London, 1999). Van Der Weyden quotes from the book: "The limited prospects of future medical advances should now be well recognized." It is contended that in the 80¼s there was a loss of optimism in modern medicine brought about through a decline in clinical science, restricted drug safety regulations, and the intellectual and emotional immaturity of the medical profession in the uncritical use of technology. The book proposes that the resultant intellectual vacuum was filled by "the new genetics" and "the social theory" of epidemiology with it¼s disease prevention focus.! "Their failure is the fall of modern medicine" and Van Der Weyden further notes that the fall has been accompanied by disillusioned doctors, the worried well, the soaring popularity of alternative medicine, and the spiraling cost of health care. The MJA editor concludes, "What are we to make of all this? All is not well with modern medicineä.¾ Am I just going to criticize our undergraduate education system, and the 16 presidents who signed the ACC document, or do I have something constructive to offer? I offer the following thoughts as a starting point for further discussion within the profession: 1. We should begin to explore teaching chiropractic students (especially in relation to the basic sciences) in ways that better reflect the fundamental philosophical constructs which we ascribe to. The profession should make a priority of putting together a philosophy of chiropractic curriculum review process in order to ensure that what is taught at all levels aligns with, and reflects, the fundamental philosophical constructs and core values to which chiropractors ascribe. 2. Having basic science educators, with little to no past experience of chiropractic, come in to a chiropractic college and educate chiropractors is just not good enough. In the short term, chiropractic educators from outside the profession, should, at a minimum, undergo a 12 months training program in how their area of expertise relates to the philosophy of chiropractic. In the long term, the profession should make a priority out of developing courses that educate the professions educators. 3. I do not agree with teaching chiropractic students more pathology, and as much microbiology as medical students receive. We should not be copying the undergraduate curriculum used in medical schools, and we should not be loading courses with subjects that will look good in the eyes of regulatory bodies. Again undergraduate course curriculum should reflect the needs of becoming an excellent chiropractor, and not learning how to become a source of referrals for the Biomedical establishment. 4. A larger percentage of the Chiropractic undergraduate curriculum should be devoted to teaching students how to think critically and creatively. Integrative classes should be developed in which chiropractic students are led through a process of reflecting on the rest of their subjects and clinical time in light of chiropractic principles. 5. A broadening of subject matter should be facilitated so chiropractic students become more aware of their role on social, cultural and historical levels. New subjects for discussion and integration: 1. History & philosophy of science. 2. Sociocultural studies. 3. Creative and critical thinking (The American Philosophical Association suggests that the most important outcome of philosophical study, "is the ability to engage in thinking that is at once disciplined and imaginatively creative.") 4. Critical Appraisal of the Biomedical and chiropractic peer reviewed literature from a chiropractic perspective. The crux of the problem is, I believe, that there exists two world views and many in our profession are attempting to clamber aboard one (which happens to be on the decline) whilst still saying we ascribe to the values of the other, to which public affiliation is rapidly growing. Biomedicine has much invested in holding on to its core values which are born out of the outdated and inaccurate assumptions underlying the Newtonian world view. Unfortunately for Medicine, Western society is at a cultural cross-road and is desperately struggling to find its way toward a unification of mind, body and spirit. I believe our society is about to go through what might best be likened to a phase transition. In coming to terms with the collapse of those institutions and beliefs that reflect the Newtonian world view, the members of society, are and will increasingly be, looking for a new world view and institutions and beliefs that accord with that world view. Despite where society goes in it! s search for meaning I believe each of us, as members of the chiropractic profession, have a responsibility to eliminate the contradictions between what we believe, say and do. We owe the vigilant pursuit of contradiction elimination to those chiropractors who went before us, and those who are still to come. Moreover we owe it to ourselves, our patients and indeed all of society. Our profession's future lies not in jettisoning our metaphysical past, but instead, in embracing and evolving it in light of what a more chiropractic friendly science might reveal to us - (A mix of qualitative/quantitative/ phenomenological sciences combined with the asking of paradigm relevant questions). I think that if we do the right thing with our science, it ,and a mature philosophy of chiropractic, could have as much of an impact on the sciences of biology, physiology, and biochemistry, as what Darwinian theory had on Paleontology, Anthropology, Archeology....... I believe students, the profession and all of society will benefit from our best efforts to remove those Rheumatologist tinted glasses from the minds eye of those destined to become future chiropractic educators, practitioners and researchers. Until we do that, we should avoid at all cost, on a political level, sacrificing that which is most important [philosophical constructs] on the alter of that which is least important [Recognition from the Biomedical model]. In summary, remaining separate and distinct must be a priority for the chiropractic profession. We should learn from the example offered by the US osteopathic profession. Students, whilst being schooled in all aspects of the chiropractic undergraduate curriculum must be taught, both in terms of content, and methodologically, in ways that reflect and reinforce chiropractic¼s fundamental philosophical constructs. Ending up with graduates prescribing antibiotics and other medications speaks loudly of our academic institutions failure to achieve a separate and distinct undergraduate curriculum which I contend must necessarily proceed our achieving separate and distinct status on a professional level. Sincerely, Adrian Wenban B.Sc., B.App.Sc., M.M.Sc. Accommodating Intraprofessional Dr. Winterstein Responds Diversity James Winterstein, D.C., D.A.C.B.R. President National University of Health Sciences There is a lot of talk recently in the profession about unity. It is ironic that this profession has not been unified from the very start and still we go on and on about this idea. I wonder, "after a century of this rhetoric about unity, has it not occurred to anyone that it is not going to happen?" A brief review of our history will tell anyone willing to spend the time to read it, that this has been tried and tried and always, on the Monday after any kind of unity event, there was a new organization, a new standard, or a new school. What is it about us as a group of people that keeps us from accomplishing professional unity? I think the primary reason is that we are normal humans who want to think of ourselves as progressive and openminded. Think about this for a moment. What other profession can we look at as a model that began at least a century ago and remained exactly the same in its outlook, its purposes and its methods since its inception? Would it be allopathic medicine? Would it be podiatry? Would it be dentistry? Would it be optometry? Would it be law? Would it even be any specific religion? How about astronomy? The answer is that not one of the professions has remained what it was at its inception and yet, in chiropractic that is at the crux of our lack of unity. The majority of people do not like change, but eventually, even those who do not like change recognize the need for change as a mechanism of progress. Because the members of the profession, as normal humans have a variety of interests and desires, and because there is a variety of educational opportunities and because there is new knowledge always coming to the foreground, there is a natural tendency for normal people to want to do different things - that leads to diversity rather than unity. On the other hand, how can a diverse group of people really be a profession which has certain definitional qualities? How can a diverse group of people function as a single unit? How can the chiropractic profession be unified? Perhaps we are seeking a vision with blinders on - which does not work very well. A number of years ago, I listened to a speech in which the speaker constantly exhorted the members of the audience to "think in different terms." I believe that applies to us in this new millenium. We should seek a different kind of unity in which we recognize our diversity as useful and valuable. We have a new opportunity and we should use it to think in different terms, so here is what I suggest. First, let's review the facts: 1. The fact is that we are a diverse group of practitioners which has failed repeatedly to develop unity as a profession. 2. The fact is that within the 50 states, the practice statutes vary from those that proscribe nearly all therapies and restricts the chiropractor to adjustments of the spine by hands, to those that permit the chiropractic physician to treat a wide range of internal disorders, cast fractures, suture wounds and utilize a wide range of therapies other than the spinal adjustment. 3. The fact is that within the 50 states, practicing chiropractic doctors engage in all of the legally allowed practices, from the most restricted to the most broad. 4. The fact is that every talk about unity does two things - it tries to move the broad scope practitioners into a more narrow scope and it tries to move the limited scope practitioners into a more broad scope. 5. The fact is that standards of education and practice are always in compromise because of the desire to make them more restricted by those who practice that way, and to broaden them by those who practice that way. 6. The fact is that some chiropractic doctors support immunization by vaccination and others vigorously fight the concept. 7. The fact is that we have not yet demonstrated, through scientific evidence, that spinal subluxation is a causative agent in human disease or dis-ease, nor that we can actually "correct" subluxation. Yes, we have demonstrated that some kind of spinal joint discord produces pain and other symptoms and we have demonstrated that manipulation of those areas of spinal discord can relieve the symptoms, but that is not the same thing as validating subluxation of spinal vertebra and correction of this entity by what we prefer to call specific chiropractic adjustment. 8. All of the above are clearly recognized facts that affect any attempt to develop unity within the profession, and have always, sooner or later, subverted the process. With these facts in mind, how do we proceed in this new millenium, to come together as a group of practitioners into a profession with common goals and interests. If we think in different terms, I believe there is a way and it is called intraprofessional accommodation. How would this concept work? Here is what I think. Intraprofessional accommodation The words have a clear meaning. Within the profession of chiropractic, with all of its diversity we must learn to accommodate the diversity itself. Isn't that what our entire society is struggling to accomplish on a broader scale? In our society, we don't like someone else because of his or her color, or habits of living, or ethnic celebrations, or peculiar language and on and on. One would think that as a minority profession that has experienced a lot of discriminatory persecution, we would have the good sense not to do it to ourselves and still we do. This intraprofessional discrimination needs to end first. Granted, because we are a health care profession, there are certain ethical and legal responsibilities that we owe to the people and its governing bodies. Those, we must agree to meet. Above that level, we can develop intraprofessional accommodation. We can agree to let those who what to practice a limited or specific scope of chiropractic practice to do so. Likewise, we can agree to let those who want to practices an expanded scope of practice, do so. In both instances, the practices must be determined within the profession on the basis of education and experience and not by outside agencies. It is exactly at this nexus that we have made our most significant mistakes in the past. If intraprofessional accommodation is to work, we must not make the same mistakes in the future! We have legislated the parameters of our profession - actually lobbied to have the laws determine what we can and cannot do! No other profession has done this as we have. Even the anatomically limited professions (of which we are not one) such as optometry, podiatry and dentistry, have worked to correct their errors by lobbying for, and obtaining expansion of their scopes. If we truly want to have intraprofessional accommodation, then we must agree to work toward removing practice limitations from the state statutes. Some would say that is not possible, but they are wrong. When we wanted the CCE Standards to be part of our practice statutes, we made it happen. When we wanted to move from the requirement for basic science examination and certification to a National Board Examination, we made it happen, and we can make this happen too if we agree to work toward and for intraprofessional accommodation. Some will say that this will be confusing to the public. Really? How would it be any more confusing than our current situation. Let's face the reality that we are a diverse profession and that is not going to change. We should use this to our advantage when we talk about chiropractic to the public. They will understand - that is the least of our worrys. It is interesting how nothing is new. I have been writing about and promoting this idea, of working to broaden our legislation on chiropractic scope of practice and allowing limitations within the law as a matter of personal preference, for some time. Just the other day, I was reading some of Dr. Janse's writing and here is what I found "always legislate as broadly as possible so you can practice as narrowly as you choose." It did not happen then, but it does not have to be the end of the story. Now we have a new opportunity. Talk to your colleagues - try to persuade them to think about the concept of intraprofessional accommodation. It is only through this conceptual framework that our profession will be able to unify itself for the benefit of patients everywhere.