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Writing about the future of anything is risky business. Putting a wager on where anything is going is certainly akin to gambling or betting a line on a sports game. Some approach this futuristic stuff by outright guessing, others with percentage odds of potential future scenarios based on data and trends. Others go about it by just asking those in the current know what they think. I’m going with a bit of a combination of the above because after almost 35 years of practicing chiropractic I have learned that the more information you have to help you make decisions the better your guesses.
This section builds on the earlier sections of this chapter by my colleagues, Drs. Bart Green and Robb Russell, and will attempt to forge a bridge from that fact-based story about chiropractic into a theoretical one about what is coming to the chiropractic profession. In my story, I will be looking at the views of people that know our profession and because of each of their positions they have their own special insight into a critical portion of the profession.They will be extrapolating to a degree based on what their perch over the profession has brought into their field of view. While there were a few with overlapping views, most gave a new and insightful perspective on where the chiropractic profession is going — and I owe each of them a deep level of gratitude. They are all listed in the reference section for this chapter.
The obvious problem with my approach is that I am consulting with people who are currently in the know. Change, however, in any endeavor often comes from people who are not thinkers that are confined by the boundaries of current way of doing things. The future often comes from those who look at what exists, see the flaws in the system and then work out ways to carve out a niche or build a structural base of support for a new, and possibly better or more efficient, way to do the job but might require destroying the current way of doing things.Disrupted is the current way we describe this.
We are all familiar with the history of many processes that have been transformed.Consider transportation or communication and how the initial innovators were displaced by those with new and typically ingenious ways to build on what was in existence in a transformed way. The domestication of the horse was revolutionary. It transformed the speed of our communication, our trade and transportation,how war was fought and expanded food production along with many other things. Now,however, for most in the first world, horses are typically just a fabulous hobby. There is certainly only so much critical thinking that experts can do when they are really dealing with the known knowns and known unknowns.
Just to put an even deeper blanket of haze over this whole forecasting thing let us not forget that chiropractic is only one small part of the healthcare world. While we are not insignificant, we are small enough to mostly not be considered when health care policy makers go about their business. Certainly, we have done a good job of existing at the fringes of the models that exist in healthcare but, from a structural standpoint, we have never had much of a chance of existing at the center of, in a spoke and wheel sort of way, the business of healthcare delivery. And those business models are certainly changing from those that have been built around relationships with hospitals to one designed more with the medical group as the spoke around which the other players exist. This trend may be an opening for the chiropractic profession.
A final level of critical evaluation to this future prediction business is that it will be done through my eyes and the eyes of those I have come to know. Certainly, this is suspicious. I have however, listened to those I interviewed and followed up, as best as I could,with other experts that were recommended to me. However, given all the reasons that this entire section of the manuscript might be just a “Boat of Foolish Smells”, we shall forge ahead regardless and hope that we can ask for forgiveness at some future date if our representations have been amiss.
Avast! Let us sail forward into the unknown...
It seems that a day does not pass with health-related information splashed across the news. Everything from new and better ways to treat specific diseases to new disease outbreaks to breakthroughs in care delivery and care processes. In the US, health delivery systems are constantly merging or divesting portions of their business or new models of care are being tried out in an effort to provide care that will drive efficiencies, profits, quality or value to the care seeking public. What with up to 25%of all US healthcare delivery being considered wasteful and over 30% of lower back pain care being discordant with guidelines, there is ample opportunity for new and innovative ways to improve efficiencies and provide value while cutting out healthcare delivery waste.
Enter Big Data and maybe Big Brother.With the digitization of healthcare data,through electronic medical records and tracking healthcare encounters through billing, the opportunity to document and evaluate what has happened during a healthcare encounter grows with every new byte and bit of data entered into a healthcare provider’s computer. While data has been entered into computers for decades,it is the advent of the network and the cloud to store all of that data, combined with software to perform data analytics, that is leading to new and better data driven decision-making and strategy. Eventually, with the advent of deep learning and large volumes of data collected over time, artificial intelligence will create opportunities to transform our understanding of healthcare and our ability to make impactful healthcare predictions. Starting with the tracking of the main reason for healthcare encounter (diagnostic codes, procedure codes,etc.), matched to any co-morbidities or related diagnosis, paired to the specific provider type seeing the patient and then the exact provider that is performing any procedures or giving prescriptions — everything is becoming known about what happens when caring for a health condition.
What then becomes of all of our very personal data in a medical record when that information gets woven into the data fabric of our electronic life? Meaning, consider the individual lifestyle choices and personal goals each person has along with their work and family requirements, where they live and how long they commute along with their ethnic and religious background and everything else.Much of that data will be entered into the medical record, evaluated and tracked and then combined with data from every other patient healthcare encounter with similar clinical parameters. It will create a 360 degree view of an individual in the healthcare system and formulate that patients likely next best step forward in dealing with their health concerns.Pair that data with the historical data of each provider treating each patient in the healthcare system with their individual conditions and it is likely that the system is going to be able to eventually have the ability to predict outcomes for each patient by a specific provider or a category of providers. Meaning,recommendations may one day be made to the each patient, by whomever is in control of the data, as to exactly which provider or group of providers will be best for a specific patient and/or the specific health concern of that patient. This is beyond centers of excellence —it will be truly personal and customized healthcare based on real data that will make actual predictions on what will be the best care pathway for each patient’s condition.
So, everything will be measured and evaluated, right? Well, yes, except when there is no insurance carrier or other entity being billed or the data being collected is not shared within a larger healthcare system. This lack of participation, from an electronic data collection perspective within large healthcare systems, is relatively frequent in the chiropractic profession and other professions in the non-medical healthcare provider world. Additionally,medical providers in small practices, those still paper charting and concierge practices likely constitutes a not insignificant amount of care.If data is not being submitted by a subgroup of health care providers into the vast pool of patient data, in the new data gathering age we are in, will the care data being done by those providers who are off the grid be forever lost? That is very likely. Classical research on what those providers are doing can help but, it appears to me that we are moving into a captured data driven decision-making era.Studying healthcare with traditional research methods (randomized controlled trials, etc.) in a well-designed and organized fashion,which is how most healthcare research to date is done, for conditions treated by physical medicine practitioners, will likely be seen as less helpful and likely less accurate than the real data captured on millions of patient encounters over an extended period of time.In a world where every bit of healthcare data on those individuals is known, as it eventually will be, that information, and the predictions that will be possible, might be closer to the real truth as compared to what a controlled research study can tell us. So, will the nonparticipants in healthcare data capture become vestiges of healthcare? It makes one wonder if that is possible but, certainly, care decisions and best practices will be determined outside of what those non data providing providers, who are working in data deserts where healthcare information is non-capturable, are doing.
At this point, a flaw in this line of thinking must be revealed — the regulatory environment.Currently it is either not possible or uncommon to be able to take data captured by an electronic medical record (EMR) and blend it directly to all of the billing and coding data for an individual patient throughout their entire healthcare journey. Large at-risk organizations have the ability to do this because they have all of that data. In most situations though, there is the insurance entity data (billing and coding of every health encounter) that has encounter data and then the EMR that has data the healthcare provider is using to collect specific healthcare information on each patient, patient encounter and everything associated with that patient including their individual lifestyle habits and preferences. There is too much to be gained for this data not to be joined seamlessly and this is what large data gathering organizations have been working to achieve and will likely achieve in the not too distant future, if the regulatory environment allows it.
And, what is the point of data analytics in healthcare? As described above, data will help with the understanding of exactly what is being done during a healthcare encounter for each individual patient. Which types of encounters and care pathways and maybe the specific provider that is most effective for each patient will become much easier to understand with big data. It will likely lead to training opportunities for providers who have less identified proficiency in caring for certain patient types which may revolutionize healthcare provider training.All of this will lead to new efficiencies in care delivery and more appropriate decision-making. Given chiropractic’s success in neuromusculoskeletal (NMSK) care, this new world of data gathering and data analytics will lead to data driven care pathways that will likely be favorable for the chiropractic profession.Where I work, we have already begun to put the positive data that has been gathered in physical medicine (physical therapy and chiropractic care) to work. Discussions have started about how to get nurse triage calls routing patients to the appropriate provider for that patients first encounter as opposed to just defaulting to referring the patient to a medical doctor —which is the healthcare system standard. Other provider groups, Crossover Health for one,have already put the focus physical medicine providers seeing the NMSK patients as the first point of contact to their clinics. This trend has the potential to be a huge boost for the chiropractic profession.
All of this data gathering is not without controversy. Will Big Data beget Big Brother,or more probable, Big Hackers? Data security is a well-known concern to all of us. What will happen when all of an individual’s health data becomes known to the hackers of the world?Other than putting individuals in a potentially compromised position if information about their health concerns are publicized, I’m not sure there are any concerns to the individual.That is not unimportant though — an employer or family member being made aware of health information could certainly create volatile situations with significant repercussions.Potentially more concerning is that patient identifiable hospital data is now being shared with technology companies. While many good things can happen when evaluating data, one must wonder if this will eventually lead to nothing more than marketing opportunities for our for-profit healthcare system — particularly the pharmaceutical industry. However, given that this data gathering has already been happening, it has generated very positive findings when comparing chiropractic care to others for spine care. And this has already resulted in positive changes. Optum (United Healthcare) has already announced benefit changes that allow 3 free visits to patients with a spine problem if they see a physical therapist or chiropractic provider. A positive event for the professions indeed. Again, given our history with data gathering so far, it is very likely that what comes out of any future healthcare data is going to be very positive for the chiropractic profession and will drive changes leading to growth in the number of patients being driven to chiropractic providers by the healthcare system.
Prediction: by 2030 data analytics will have been driving healthcare organizations to refer spine pain patients to doctors of chiropractic and the trend will be to send all NMSK patients to chiropractors or other providers with skills that are traditionally best handled by doctors of chiropractic. This could increase the number of patients being directed to seeing a doctor of chiropractic by the medical system to increase several times over what it is today. This has the potential to increase the total number of patients under chiropractic care by up to 50% a year. Meaning, instead of treating 10%～15% of the US population, the percentage of the population under chiropractic care could be between 15%～23% of the US population by 2030.
Next let’s consider all of the devices connecting individuals to the internet and the implications to the chiropractic profession.All of those things, those devices, those tiny computers, even just chips or wires that are collecting personal physiologic data and are connected to the internet. From smart watches to posture monitoring devices to everything else imaginable when monitoring body functions —the IOT, Internet of Things, has evolved and been subdivided into the internet of medical things (IOMT) and several other sub categories.These devices have the ability to significantly change the day-to-day activities of all healthcare providers, doctors of chiropractic included.
Now that everyone is familiar with FitBit,smart phone, especially the iPhone and their abilities to monitor our activity and physiology where will this take us? IOMT unleashed! I am not going to go into a complete review of all of the devices available and other technology currently available or even everything that is on the horizon. At this point smart clothing,E-textiles and sensors in our attire are all available to monitor and potentially enhance our lives. What seems more prudent is to briefly review current technology that directly impacts the chiropractic profession and what is being discussed as coming in the near future.
Here are a couple of the established technologies that have direct implications to the practice of chiropractic.
There are posture monitoring and training devices that patients are already ordering and trying in an effort to improve their posture.UpRight, based in Tel Aviv, has been in this space since 2015. At the clinic I work in we initiated a trial program using the product starting in 2016. Patients found them helpful,although a bit intrusive. At the time they were promoted mainly for lumbar lordosis training when sitting. While we found that it was helpful, we decided not to fully integrate the product into our daily practice. Today I generally have a few patients a month trying the product and asking me about it. Generally,they are very happy with the product. They feel it does help them work towards correcting their posture problems and for most of them, in my experience, it does. What has been missing is the ability of the device, which adheres to the spine and buzzes/vibrates to alert the individual when their posture is poor, to provide feedback to the provider and to integrate the data into the providers EMR.
Sensors in our foot apparel are another IOMT component that has already been available for years and allows many of the mechanical components of walking and running to be evaluated and tracked. There are several examples of this in socks and shoes. Sensors are being woven into fabrics that measure the positional/postural issues of the body parts they cover as well as muscle activity and muscle fatigue. While currently most smart fabric technology is in the experimental stage, there are garments available that monitor this now.Will this data make it securely to the user’s cell phone and then be pushed to a healthcare provider’s EMR? It will be a major game changer in how the chiropractic and other physical medicine providers practice once it does. Tracking activity levels and posture over time will create a road map of a patient’s biomechanical activities. If integrated with pain measurements, imagine the ability to prevent the chronic problems from poor posture or improper biomechanics that will be possible.Since poor posture might be something that occurs only at a certain time of day, the unveiling of this data to the individual wearing it and the provider, when that happens, will facilitate communications that hopefully will help to pinpoint reasons for flare-ups and ultimately help to prevent problems.
While I have been told that getting IOMT data from the user’s cell phone into the EMR is being worked on and that each IOMT company includes this as part of their roadmap, there are still many hurdles for actual patient data to get into the providers chart. Agreements between each IMOT company and each EMR company are needed and the technical issues of transferring data securely need to be worked out. But just imagine it was possible to do this. A patient wearing the device all day, capturing a day’s worth of postural information and regional muscle activity. That alone, documenting any positive or negative situations and changes, would be incredibly helpful in managing a patient. What if they also input their level of region-specific pain into the system at regular intervals (say hourly). It would then be relatively easy to track their pain as mapped to their postural history. That data would obviously be very helpful pointing out problematic situations and allow the patient and provider to review how to avoid those moments.It would likely help in tailoring specific rehabilitation exercises for each patient based on a specific set of demonstrated biomechanical faults during their daily activities. Everything from ergonomic discussions, exercise choices,reviewing sleeping positions would all have actual hard data points and lead to less guessing as to how to best avoid the causative situations and activities that are likely driving the patient’s problems. This, if ever fully implemented, will likely lead to a significant improvement in the quality of people’s lives and create an entirely new desired skillset for chiropractic providers —remote communication and remote patient education.
Now, what about devices listening in on patient encounters? With smart speakers in the home now, one would have to think that eventually Siri and Alexis will be electronically hovering over our every word during a patient encounter. At this point I think we are very far from that being a reality that results in changing a patient encounter. But, one day, as the technology advances, one would expect this to significantly change the healthcare provider and patient encounter. Imagine no typing into an EMR, being questioned about performing an additional orthopedic or neurologic test, or maybe advised to evaluate another potentially related body part or organ system.What if outcome assessments were populated automatically based on the verbal interaction of a patient encounter and red flag question lists and potential lists of differential diagnosis were verbally generated by the smart speaker?Automatic specialist referral recommendations,nutritional options as well as general exercise recommendations might be mentioned by the smart speaker and video’s demonstrating exercises might be cued up onto a screen. The list of potential new eventualities is pretty extensive. I believe all of this is coming but it is obviously a very long way off.
What certain is that humans will become more and more machine like as we evolve to wear more devices to help us monitor our functioning and ultimately to help us perform better and for longer. Providers will need to stay aware of these changes and learn how to best incorporate them into the home care advice that they give patients.
Prediction: by 2030 most people in modern society will have several monitoring devices connected to their body and that data will be shared with providers who will engage with the patients remotely on the findings of the IOMT device.
In the US, doctor of chiropractic programs are becoming more competency based and are starting to steer away from teaching to specific requirements. When compared to the training of other healthcare professionals we certainly stand alone, from an institutional standpoint in the US. We are not tethered to larger university systems since we grew independently of other educational systems. Chiropractic’s professional origins go back to a time when many of the medically affiliated professions (physical therapy, behavioral health, nutritionist) were not fully in existence or were not part of the medical profession or medical care paradigm.Having gone our own way from an educational standpoint, we have stayed independent for the most part and have not developed the type of training that most other US health education programs have done with hospital-based programs and internships. This may be to our advantage because we have had to learn to be independent but it is possible that the future of our US based training institutions will become more integrated along these lines. This would mean incorporating learning with not just other ancillary health professions as is happening, but with the traditional medical aligned professions of medicine, nursing, podiatric, physical therapy and all the others.
I have heard that there are concerns trying to teach to the requirements of 50 different states, particularly a state such as California where licenses are based on an Initiative Act enacted in 1922. The concerns are with adhering to all of the requirements of something voted into law nearly 100 years ago as well as newer requirements that come from states with different ideas about chiropractic. Is it possible licensing changes around education will become less of a state regulatory requirement with more of the educational requirements being federally mandated? That seems unlikely but, there is a sense that some regulatory changes might occur to streamline the educational process.
Residencies, which are the standard in many other health care training programs, are rare in chiropractic. The Veterans Administration is the only good example of using DCs in residencies and it only serves a very small percentage of the chiropractic graduate population. Any growth of that program will help to increase the job placement of the residents into integrated settings but will certainly only continue to involve few DCs. At the current time, there is no indication that an additional entity will appear to help train chiropractic residents.
Accreditation standards have changed over time for chiropractic colleges and education delivery and assessment has and will continue to change, but towards what end? Federal agencies have looked at graduation rates and student loan default rates as potential indicators of how effective educational programs are.Is that data meaningful or will it drive any changes in how doctors of chiropractic are trained? That is difficult to know. And, we really do not know what it actually should cost to train a DC and if rates of graduation or passing National Board of Chiropractic Examiner exams or success in practice have anything to do with this. As far as training goes,has the technological revolution done anything to revolutionize chiropractic training? Not much so far. There certainly is a huge opportunity to centralize the basic science portion of chiropractic education through the pooled use of technology. Will privately held colleges link together so that one lecturer with expertise in the basic sciences can lecture to the students of all or many of the chiropractic colleges with distance learning technologies? It has yet to happen or, from my understanding, even be openly considered. If it did, it certainly would allow, in theory, the best teachers to teach and those that are not to explore their other talents.There is no doubt that this would start the process of bringing down the cost of delivering a DC degree. I can imagine that any group of administrators who started down this path might end up jobless themselves prior to this being implemented — but it does make sense when viewed through the lens of making education more affordable. Given the current high student loan burden of chiropractic graduates,it seems that the lack of implementation of a distance learning component to the doctor of chiropractic curriculum will certainly continue to burden the graduates in a financial way and negatively hinder their potential success. This alone, one would hope, might be impetus enough to have the process initiated on some campuses.
The US standards, put forth by the CCE,require programs to establish their own mission,along with goals and objectives that define how they are going to measure their success.There are some common elements and some unique nuances that are defined and measured by each doctor of chiropractic program. If the measure of success of the educational program were made by looking at performance from the prospective of the end user of that program,the doctor of chiropractic, then maybe all of the factors that ultimately lead to success would be considered. Certainly, passing tests and boards are important but so is the total time and cost of the program as well as the ability of a graduate to perform as a DC in a private office or in a healthcare delivery system. What is the importance of instituting the notion of life-long learning, or to be true to the history and principles of our profession?Should we measure the educational success by the ethical leanings of our graduates or the quality of care or value to the healthcare system provided by our practitioners? All of these are concerns and it will be up to each institution to decide its individual path. Let us hope that there are chiropractic training institutions that find commonality in their approach and are able to co-resource certain components of their educational training process to allow the end user to benefit financially from these efficiencies. If something along these lines does not happen, it will limit the number of students entering the profession and lead to shortages of skilled providers of badly needed services. It is possible though that if the income of graduates significantly accelerates it could easily offset the continuing increasing debt load of chiropractic college graduates. Eventually,if data continues to support the chiropractic profession as being a provider of high quality and high value care, it is certainly likely that the larger healthcare educational systems will want to incorporate chiropractic into their programs.This could, given the public support of these types of systems, result in a lowering of the total debt burden on the doctor of chiropractic graduates.
Chiropractic has always been a service that is directly accessed by the public and this continues except in a few situations where the medical delivery system requires a medical doctor to initiate any specialist(non-primary medical doctor care) — such as currently is the case in the VA. The procedures,recommendations and adjunctive therapies the profession performs have been based on a more natural and non-invasive approach to health care. The case has been made that medication prescribing should be added to a chiropractor’s scope of practice. It is possible that this happens as there are examples of it now but imagining this as a growing component of the chiropractic scope of practice is difficult.There are advanced practice providers including physician’s assistant and nurse practitioners that are rapidly filling the need for these services.Currently, if the value of chiropractic services were fully realized, there would not even be close to enough doctors of chiropractic to fill the needs of the public. Additionally, any foray into this sort of increase in scope of practice will be costly and vigorously fought by other providers. Imagining the prescribing of medications as something that gains traction for the chiropractic profession in any significant way is very difficult at this point.
When looking at accessing a doctor of chiropractic from the patients’ perspective,historically a visit was one that required the patient to pay cash for the services. Through the 1970s and 1980s chiropractic gained insurance coverage in most reimbursement settings and currently is covered by the vast majority of insurance plans. That coverage does not necessarily mean equal coverage as often times the amount a patient must pay out of their pocket for a course of care with a conservative care provider, chiropractic included, is significantly greater than the cost to a medical doctor for a potentially dangerous and highly addictive medication. As of 2009, likely influenced by the aforementioned policies, the US has acknowledged that it has an epidemic regarding the abuse of opioids. Because of this,legislation to avoid the addiction, overdoses and deaths that have followed opioid abuse are supporting conservative care for pain. It has created an interesting twist in the history of healthcare at this time. While access was granted to many conservative care approaches through reimbursement, those approaches were never put into the forefront of the care pathways that were used by the medically managed healthcare system. Now, it seems,in this world of data management, quality and metrics, a path of conservative care seems to be the one currently enlightened by the literature.Individual state regulators are looking at ways to stop the opioid crisis as well. Legislation in West Virginia was signed into law in 2018 to require that any prescription for opioids also requires a prescription for an evidence-based form of conservative care that can include chiropractic. Other states in the US have, or will be introducing similar legislation as well. With this as a backdrop, the American Chiropractic Association is supporting legislation that would increase access to services by chiropractors in the Medicare system and, if signed into law, would bring the current antiquated reimbursement system more in line with the way that population is cared for today.
There are those in the reimbursement world who are looking to get ahead of this trend towards better conservative care and are basing their approach on what their many years of insurance data has shown. One large US insurance carrier is considering removing any out of pocket costs for patients with a spine problem if they see a conservative, non-MD, care provider first for their problem.The conservative care being considered will certainly include chiropractic care. Since it has been shown that chiropractic patients are very price sensitive, this would clearly incentivize many patients to choose chiropractic and create a very large influx of patients into the offices of doctors of chiropractic. This would be an amazing turn of events from the years of increasing deductibles and co-pay for chiropractic services.
Prediction on chiropractic training: Within the next decade it is likely that there will be at least some US chiropractic programs that will have merged together and others that will have joined with established healthcare training educational systems. There will also be a sharing of resources between some doctor of chiropractic programs which will help to decrease the debt burden on the graduating doctor of chiropractic.
Prediction on scope of practice: Over the next decade the scope of practice of chiropractic practitioners will be largely unchanged.
It is now clear that spinal disorders are a serious and important problem in the world as evidenced by the series of papers published on “Global Spine Care” in the European Spine Journal. Spine problems, as of 2018, have become the 4 th leading cause of disability adjusted life years just after ischemic heart disease, cerebrovascular disease and lower respiratory infections and that grew from spine problems being the 12 th leading cause in 1990.Given the trajectory of this problem and its prevalence it would appear that the opportunity for the services the chiropractic profession delivers is growing significantly.
What is less clear, based on that same group of papers, is which category of health care professional will be the preeminent spine care provider. The importance of spine care and the specialty information required to be an effective spine care provider are becoming known and taught. One has to wonder who will control spine care given this current body of evidence. If health care policy continues to identify spine problems as a significant cost driver and producer of great disability,the need to move towards a more generalist approach to spine care will likely occur. It is not difficult to imagine, as many have suggested,that eventually healthcare will treat the spine as a specific organ or body region, much like the dental profession approaches teeth. In that scenario, who will fit into that professional role? There may be a need for some providers to re-tool or update their diagnostic skills,evidence-based knowledge, manual procedure skills, rehabilitation skills, communication skills, team-based integration and interprofessional referral skills.
There are many professions who all play in the spine care space and it may be that an integrated team will be the best approach to spine care as this is now seen in some areas.Imagine a doctor of chiropractic, doctor of physical therapy, medical or osteopathic doctor who possesses the skills to diagnose and treat with evidence-based procedures, all that has shown to be effective for spine care. Who would do the best job? Currently the physical therapy and chiropractic professions would seem to have the largest numbers of providers currently able to implement most of the skills that the evidence seems to indicate as being effective. However, doctors of osteopathy, who have taken the time to acquire and then fully develop the appropriate skills, may become well equipped to be put into this role given their ability to prescribe the few medications that have been shown to be effective for spine conditions. The medical field, with its inherent lack of focus on manual body work, currently does not seem to be the best fit for this portal of entry provider who can initiate care on the initial visit. And, nobody should be so bold to think the book is closed on exactly who, or what skillset is best, to be the perfect spine care provider. At this point it seems that a teambased approach is best utilizing several types of different providers. While it is possible that a team is needed, the scope of the team may vary based on the individual skills of the team members. As previously mentioned, we may need to start by taking a look at outcomes from large sets of data to find practitioners, or specific groups of practitioners, who get great results that last the test of time.
Some are concerned, as it has been discussed for decades, that the chiropractic profession is indeed heading for a split between those who want to be condition focused on patient care with less focus on wellness and those who want to be wellness focused with less focus on caring for conditions. Doctors of chiropractic are not the only provider type that has providers with significantly different focuses. The acupuncture profession and other profession have this same potential split between traditional wholistic only providers and those providers willing to care for regional conditions. I think that after well over 100 years, we are not going to split. This profession has many different flavors and two or more categories of providers. Will we continue to confuse the public because it will be difficult to find another provider like their prior doctor of chiropractic? Yup. But that will not be a significant obstacle to success and growth of the chiropractic profession. Patients will gravitate to the type of healthcare provider that resonates with them and tell negative stories about the providers who did not align with their idea of what a doctor of chiropractic should be.
Chiropractic has grown from virtually no integration at its inception to now being integrated into the most multidisciplinary practice opportunities available. Included in the vast array of these types of practices are stand alone practices that can include DCs with any of the following and more: massage therapists,acupuncturists, physical therapists, athletic trainers, behavioral health providers, and an array of traditional medical providers along with some of the newer advanced practitioners.Then there are the standard medical practices that can include DCs, hospital settings,specialist medical offices, community clinics,corporate clinics, the Department of Defense,the Veterans Administration hospitals and clinics and others.
The fact is that the growth of chiropractic in integrated clinics is significant and appears to be something that will continue for an extended period of time. The number of DCs employed in the VA has the potential to double or more than double over the next decade and the growth in on-site and near-site clinics will likely continue at a greater rate than that. Chiropractors practicing in a hospital setting might not experience significant growth, as the ability of a hospital to make a profit off of a DC is limited.In the future, if there is significant growth in hospital based Accountable Care Organizations,the picture could change dramatically as chiropractic providers certainly would help to limit the cost of employing more expensive specialists. Between the Department of Defense and medical institutions generally, there is significant opportunity for growth of DCs who are effective at treating NMSK conditions to be employed. The problem is trying to gage a growth trajectory for integrated providers when we do not even have a good idea of how many DC’s are currently employed in these positions.
On the competitive front, physical therapists have been granted direct access to patients,often with restrictions on that access, in the majority of states and this enables them to directly compete in the public eye for those same patients that would typically walk into a chiropractic doctor’s office. Will this lead to a decrease in the number of patients seeing chiropractic practitioners, the indications are certainly not trending that way? After practicing with many different physical therapists over the last 12 years, many still have a way to be comfortable and competent in caring for patients without another provider’s referral.There certainly are physical therapists who are much better at this than others and those better prepared providers have the ability to make patients comfortable with them as their portal of entry NMSK provider. In my experience those providers are not in the majority yet.Additionally, doctors of chiropractic have a different general approach to care than do physical therapists and the public can readily tell the difference. The other thing I have experienced is that we work very well together once we understand each other. We all learn from each other and come to understand our individual strengths and weaknesses. It makes the two professions perfect to work together to help patients not only recover from a problem but to help that patient to better learn about avoiding a return of that problem in the future.Since our professions do have similar skillsets regarding some practice styles, there will be the inevitable turf war scuffles. Fortunately,the NMSK world currently is being so poorly managed and the number of patients with NMSK problems continues to grow, there is significant growth opportunity for both professions.
Prediction by 2030: I believe there will continue to be fewer providers practicing independently or in small group chiropractic only practices and those practices will be in the minority. There will be a growing number of doctors of chiropractic providing care in larger integrated practices and in medial settings generally and this will be where the majority will be practicing.
We must start the discussion of the future of chiropractic research by acknowledging that the business of going after research dollars to actually do chiropractic research was easier in the prior decades than it has been of late. While there is no real data on this, there appears to be less money being spent by US chiropractic institutions on their research faculty and, as the older researchers approach and enter into retirement, there is not a significant group of chiropractic research focused graduates in the US to continue their work. In the past, there was some work in the basic sciences looking at animal models and the underpinnings of what a subluxation is and how chiropractic works.The labs that provided those data are not in existence today to the degree they were in the past, if at all. Therefore the future of gaining a better understanding of exactly what happens when an adjustment is delivered in an animal model is stalled.
It is a discomforting statement to think that the future of US based chiropractic research is not moving into a growth phase. There is some hope of US colleges partnering with larger institutions for research dollars but there are only a few colleges doing that now and the prospect of increasing or expanding that work is very unclear. While the number of researchers in the US seems not to be growing, outside of the US the story is different. In Canada, there is a growing number of DCs who have continued education to acquire PhDs that will focus on research and the trend around the world seems to indicate the same to a lesser degree. All of this indicates that the future of chiropractic research will be funded outside of the country that was the birth of the profession, and that may just be an uncontrollable and appropriate evolution.
On a positive note, studies conducted by international researchers that have looked at the neuroplastic changes that adjustments can have on humans and their relationship to controlling pain, the potential to increase muscle strength and/or muscle relaxation are exciting. This research is evaluating some of the core principles on which chiropractic was founded. Where this research leads us is an exciting question. Will chiropractic adjustments become an evidence-based component of athletic performance care? Will chiropractic care become an indicated or even required part of every orthopedic or neurologic rehabilitation program?
All of this reminds me of when I heard Jerry Rice, named the greatest American football player of all time, speaking at Palmer College of Chiropractic West. He noted that throughout his career playing football he saw his chiropractor and was adjusted two times weekly. He said it allowed him to recover faster from games and his intense training regime. It was his ability to keep up an intense training schedule that he credited with ability to do so well during the game and particularly during the last quarter of play when the players he was going against tended to tire.While stories such as this have been a part of chiropractic since its inception, one never knows when or if the Jerry Rice approach to chiropractic will become mainstream.
A new twist into the chiropractic research story is how research into what doctors of chiropractic do is expanding by other nonchiropractic researchers. Just take a look at the journals that are typical places for DCs to submit papers, such as Journal of Manipulation and Physiologic Therapeutics, Chiropractic and Manual Therapies and Journal of Chiropractic Medicine. You will see that the papers published are typically dominated by researchers with degrees outside of the chiropractic profession or from non-chiropractic institutions. The continuation of this trend into the future certainly looks likely. What this means for the future of the chiropractic profession, to have the majority of our research being published by researchers outside of chiropractic, may be a good thing but it remains to be seen. Truly,the professional impact of research depends on implementation of the research and just because the researchers are from other professions does not mean that DCs will not be the beneficiaries of that research. It does seem possible though that the basic understanding of our profession might be moving out of our control and, given that the evidence is squarely supportive of what we do, particularly in relation to spine, it seems likely that researchers from all professions will be chasing those research dollars and looking deeper into what doctors of chiropractic do.
As far as research into chiropractic professional practice, it has been dominated by research looking at cost of care for the condition being treated, overall utilization from a cost containment perspective, numbers of visits per condition and the like. Hopefully at some point research will start to focus on the total cost of all care when a DC is treating a patient or when no DC is treating a patient, including the cost of care for the adverse events caused by the healthcare system. As mentioned earlier, this is made much easier by the advent of data driven analytics. As this happens, I believe the financial incentives for which provider to a patient will be a significant shift and that shift will be towards conservative care providers, particularly doctors of chiropractic.
Prediction: By 2030 research into the chiropractic profession will be more data analytics of care that has been provided and less traditional research as we know it today.
It has been clearly demonstrated by Palmer College of Chiropractic’s Gallup polls, that the American public utilizes chiropractors for spine problems relatively frequently. The public is very satisfied with the care they receive and the perception of the safety of chiropractic care is very high. There is no sense that the public will lose faith in the profession in the years ahead. Given this, the public’s perception of the profession seems to one that will continue to be favorable and will create demand for chiropractic services at a high level.
Certainly, one negative that has been mentioned about public perception of the chiropractic profession is the issue of the lack of standardization. We are all aware that going into a doctor of chiropractic’s office might result in one of many different types of experiences.From the history taking to the examination,report of findings, informed consent, treatment and imaging, there is no consistent approach taken by practicing doctors of chiropractic.Certainly, much of this is that we have many chiropractic techniques and practitioners of different techniques require different evaluation methods and care protocols. Many in the profession embrace the different approaches as demonstrating our uniqueness. Others complain that is confusing for patients to not be able to tell what they are going to get when the walk into the office of a doctor of chiropractic.Should we have basic standards of practice to allow patients to understand what will happen when they see a doctor of chiropractic? — Yes.Will that ever happen? It does not appear that it will anytime soon.
Prediction 2030: The public perception of chiropractic will remain very positive but with a cautious eye requiring each patient to find the brand of chiropractic that makes sense to them.
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