Specialization in Chiropractic: A Construct for theFuture ... ages, one could in fact be educated in one of these fields, ... The Journal of the CCA/Volume 28 No.
4If Editorial Specialization in Chiropractic: A Construct for the Future Michael R. Wiles, BSc, MEd, DC, FCCS(C)
It has been three years since I first published an article entitled "Specialties in Chiropractic"', and although the general trends have not changed, this paper is directed at proposing a more refined model for specialization than has been previously offered. As discussed in 1981, specialization has progressed in Canada and the United States at a relatively slow pace. In the the and U.S.A., Nutritionists, Orthopaedists Roentgenologists have strengthened their programmes and visibility, but no other serious specialty groups have emerged. In Canada, the Roentgenologists (F.C.C.R.(C)) and Chiropractic Scientists (F.C.C.S.(C)) continue as foci of academic, research and resource activities, but no clear growth pattern, trends or goals are evident. The one major addition since 1981 has been the structured emergence of a Canadian specialty group in Sports Sciences. These individuals (F.C.S.S.(C)) have organized themselves and are evolving a programme to standardize postgraduate training in sports sciences, and generate chiropractic consultants in this area. However, as with the other groups, no clear growth pattern or future goal appears evident (at least, according to published accounts). Thus what we presently have is a relatively stabilized situation in Canada and the U.S.A., with no directed activity towards standardizing specialty groups or promoting their growth in the future. To an outsider, the entire exercise of specialization in chiropractic may, indeed, appear random (vs. organized). In defense of this position lies the fact that what exists came about through the process of demand and supply. No specialty group exists without the need for such as expressed by the profession as a whole, or as demanded by the legislative, academic or research needs of our profession. But still the need exists for some framework for growth. This need prompted construction of the following paradigm.
Medical specialization patterns Medical specialists, historically, have tended to evolve from the original divisions of "physick" (medicine) and "chirurgery" (surgery). Indeed in many Commonwealth schools, dual degrees in medicine and surgery are still conferred in preference to the single degree in Medicine usually conferred in North American schools. In the middle ages, one could in fact be educated in one of these fields, quite to the exclusion of a relationship with the other. One historical source speaks of a general classification of ''toothpullers, barbers and surgeons" as an occupational designation, quite distinct from the more noble profession of physician2. From this primary division grew specialty areas in Surgery (such as Obstetrics and Gynecology, Ophthalmology, Otorhinolaryngology, Gastroenterology) and modern physicians skilled as generalists in this area are, of course, general surgeons. The primary division of "physick" (medicine) prompted the evolution of the Internist (generalist in the specialty of medicine, historically termed a physician)
The Journal of the CCA/Volume 28 No. 1/March 1984
and its subcategories (cardiology, rheumatology, oncology, endocrinology, etc.). The specialty of pediatrics grew as a hybrid of medicine and surgery as applied to the child. Radiology, likewise, is a hybrid of general medical application of a physical phenomenon, and although pathology tends to appear as a derivative of surgery, history seems to suggest that this field, too, grew first from surgery, but now is a hybrid of modern medicine (Laboratory medicine) and pathology (Surgical pathology). The basic dichotomy of medical specialties is so clear that even the academic disciplines of medical education have historically been divided. For instance, historically, anatomy has always been a discipline of surgeons, and chemistry a discipline of
physicians.
This structure for specialization in medicine seems to have functioned as a basis for other health professions to develop their specialization. Nursing, for obvious reasons, has specialized along these lines. It is with this basis in mind that we can interpret the apparently confused chiropractic position regarding specialization. For obvious reasons of historical structure, our primary role as generalists, and emphasis on the whole rather than its parts, our profession will not likely adopt specialty fields to the degree medicine has. In outlining a possible construct for chiropractic specialization, I would like to review medical specialities from a different perspective. In general, medical specialties tend to be "vertical" (that is, relating to the whole person, albeit one particular type of person, sex or age group: for example, pediatrics, gynecology, general surgery, geriatrics, industrial medicine) or "horizontal" (that is, dealing with one part of the whole, regardless of age, sex or other vertical constraints: for example, ophthalmology, hematology, endocrinology). These two dimensions can be merged to form a matrix of specialties (Figure 1) which could be expanded to include all known primary specialities (i.e. pediatrics, surgery, medicine, radiology and pathology), secondary specialties ("subspecialties", branches of the primary specialties, eg., ophthalmology, orthopedics, cardiology) and tertiary specialties (formed by the vertical-horizontal matrix, such as pediatric cardiology, gynecologic endocrinology,
pediatric ophthalmology, gastro-intestinal radiology). Chiropractic specialization: a paradigm To date, chiropractic specialization has been of a mixed type: for instance, the orthopedists (D.A.B.C.O.) are "horizontal" specialists, whereas the chiropractic scientists (F.C.C.S.) are "vertical" specialists, being experts in generalism. The nutritional and X-ray specialists tend to be vertical, dealing with the whole body, although, in practice, chiropractic radiology tends to be horizontal, dealing almost exclusively with only a portion of all tadiology. Since we deal with the whole person (and therefore, incidentally, horizontal specialization runs counter to the modus operandi of chiropractic), I am surprised that vertical 193
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specialization has not evolved more clearly than is presently seen. Vertical specialization offers the following advantages to our profession: (a) it will fulfil the scholarly and research needs of our profession, for experts in dealing with different populations of patients, (b) it will help bridge the interprofessional gap, since our specialists will be capable of articulating our role more clearly with respect to their areas of expertise. (In practice, most clinicians will probably agree that medical antagonism usually comes from the generalist ranks, and that specialists tend to be a pleasure to deal with); (c) it will satisfy the clinical needs of our profession and help promote chiropractic care. This is especially important for three groups - children, women and the elderly.
Pediatrics Our modern understanding of chiropractic science has clearly shown the relationship in the nervous system linking subluxations and disease processes: subluxations * central excitatory state (facilitation of neural pathways) * sympatheticotonia t pathophysiology 0 pathology (via tissue ischemia, neurotoxicity [eg., hypoxia, hypokalemia, etc.], or maladaptive response behavior). As has been previously mentioned, this process poses its greatest threat to children, in whom subluxation may chronically produce neuropathogenic sympatheticotonia3. Unfortunately, demographic studies have shown that less than 10% of chiropractic patients are under the age of 204 (these data obtained at a time when about 40% of the population was under 20). Given our scientific basis for modem chiropractic care, our philosophy of maintaining optimal health function and good health habits, I find it disturbing that we neglect pediatric care in the delivery of services to our communities. Here is a clinical specialty begging for birth - chiropractic pediatrics. Such a specialty group would, of course, be concerned with two vertical groups - children and adolescents. By establishing a specialist programme in this area, we would meet several needs: needs for more public awareness of the chiropractic role in child care; for greater professional recognition of this role; for more published work in chiropractic pediatrics; for spokesmen on pediatrics for legislative and other purposes; for a generation of specialist teachers for our colleges; for clinical paths of referral within our own profession for childhood problems; for development of and recognition of our special role in adolescent care (vis-a-vis the orthopedic role: scoliosis and osteochondrosis, and the neurological role: posture and its impact on neuropathogenesis).
Geriatrics On the other end of the spectrum is the geriatric patient. By 2030, about 22% of the population will be over 65 years old. Demographics reveal a paucity of geriatric patients in the average chiropractic practice4. This may be due to numerous factors, including difficult access to such patients in institutions, and the economic limitations of the elderly; however, given the need for our care in this population of undernourished, overdrugged and neglected patients, and 194
their growing significance as a proportion of the total population, it is inconceivable that specialized forms of care (and therefore specialty clinical groups) have not evolved to date. Only recently has medicine fully recognized the need for formal training programmes in geriatrics and these are not yet common. However, in time, geriatricians will evolve as a significant force in influencing medical care patterns, medical education and medical economics. It is not too late for chiropractic to reflect- its concern for the elderly by recognizing this growing population through a formal specialty group. The benefits of such a group are similar to those mentioned above (for pediatrics), as well as giving our profession a head start in planning for the most effective application of chiropractic care in this group of patients.
Obstetrics and gynecology Finally, another area appropriate for specialty development is obstetrics and gynecology. Chiropractic care of the special problems of the female patient has always been a part of our practice. In a brief article on this subject in 1980, I described the trend away from specialized chiropractic obstetric care as a political rather than clinical consideration5. In a letter to the editor in support of this position, Russell Gibbons commented on the inconsistency of our profession in supporting natural therapeutics (presumably including natural childbirth) but not supporting our clinical heritage in this area, nor the few courageous chiropractors fighting for the right to retain the ability to continue caring for their patients (eg., Dr. Laura Flores, Chiropractic obstetrician)6. Indeed, Gibbons notes that the roots-of chiropractic obstetrics "are entwined with early chiropractic and natural healing". Although a medical specialty exists in this area, there exists a specific need for chiropractic care. For instance, there is a need for specialized knowledge in dealing with the trophostatic syndrome and its attendant psychological, nutritional and orthopedic problems, with posture during pregnancy and in the postnatal period, with natural methods of pain control during the later stages of pregnancy (especially mid-thoracic and low back pain) and during labor. The need is obvious, the heritage and original precepts of D. D. Palmer are clear (Palmer's teachings included practical obstetrics). As Gibbons concludes, "it only remains for a new generation of chiropractors to recognize and regain that part of the heritage of natural therapeutics"6. I am calling on our profession to bring forth that new generation and for a portion of this generation to lead in the renewal and recognition of our heritage in treating the whole person - including children, women and the elderly.
Specialty study groups As a beginning, I propose the generation of "study groups" in all three of these vertical specialties. Such groups would consist of heterogenous membership from within our profession and would be informal.-However, they should have some central structure so that a general similarity of form begins to develop for each of these areas. For instance, each area might spontaneously generate say, ten "study The Journal of the CCA/Volume 28 No. 1 /March 1984
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groups", each of six doctors. Each group would elect a leader who could liase with a central body, for example at C.M.C.C. The three major central cores could liase, such that our new vertical specialties evolve in a similar way. This is important as a prelude for the second stage of the process. The function of these study groups would be varied: to survey the clinical area of specialization in regards to the public's needs and the profession's needs, to do clinical and demographic studies demonstrating the need for formal specialties in these areas, to publish papers and books as a foundation for growth of these areas, and to liase with the medical counterparts of such groups. I believe it in the best interests of our profession to try to co-operate with our medical counterparts as much as possible in the interests of avoiding duplication of services and providing our specialized care to the fullest extent possible. For instance, medical gynecologists would hopefully welcome conservative therapists providing specialized care for postmenopausal nutritional and orthopedic problems, for (so-called) idiopathic dysmenorrhea, for low back pain in pregnancy, etc. Likewise, a chiropractic gynecologist would need to closely ally himself with a medical gynecologist for assistance in caring for the surgical needs of his patients.
develop and regulate vigorous educational and clinical standards, including rigid continuing educational requirements. Two or three year residency programmes would have to be developed as, eventually, the only means of attaining specialty designation. All three of these areas could have their educational programmes, regulations, and general structures aligned by a central board of representatives. I envision, by 1990, a small but growing group of chiropractors with practices limited to these areas. I do not propose what I do not feel will come from evolution, moreover, it seems imperative for us, as a growing force in the health community, to put forward representatives able to influence the nature of health delivery and that these representatives not only come from the political arena, but also the clinical arena - our chiropractic specialists.
References 1. 2.
3. 4.
The future
5.
Within 3 to 5 years, these semi-formal "study groups" should evolve into formal specialty groups. Each would
6.
Wiles M. Specialties in Chiropractic. JCCA 198 1;25:8. Malgaigne JF. Surgery and Ambroise Pare. Univ. of Oklahoma Press, 1965. Wiles M. Chiropractic and Children. JCCA 1979;23:85-86. Mills D. A Study of Chiropractors, Osteopaths and Naturopaths in Canada. Ottawa 1966; Queen's Printer. Wiles M. Gynecology and Obstetrics in Chiropractic. JCCA 1980; 24:163-166. Gibbons R. Gynecology and Obstetrics in Chiropractic (letter). JCCA 1981;25:9-10.
FIGURE 1: MATRIX OF MEDICAL SPECIALTIES
VERTICAL SPECIALTIES ("WHOLE PERSON")
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(GENERAL) SURGERY
PEDIATRICS
ADOLESCENT MEDICINE
RADIOLOGY
GERIATRICS
.
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RHEUMATOLOGY
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