I have been pondering the state of health care and the failures of the system to help people who have persistent musculoskeletal pain lately, as well as some of the larger, systemic issues within my own profession.
Why do certain unsupported claims, and the associated practice styles remain within my profession?
I also wonder why certain beliefs about persistent pain refuse to go away outside of my profession, but that’s a complex conversation for another time…
I have some ideas that may explain the behaviour in my profession, based primarily on several psychological concepts. (Cognitive dissonance theory, for example.)
The expression of these systemic issues is that there is a persistence of old models of care (pathoanatomical/fragility) and practice styles (3 times a week, maintenance care, etc). This is a multilayered conundrum with no easy fix, so let’s see if I can articulate my ideas coherently.
I would like to begin with the fact that chiropractors are entitled to utilize the moniker of DOCTOR.
Interestingly, that title continues to be wrapped up with much pomp and authority, yet the separation between doctor/patient that those concepts create has been identified as a detriment to performing the duties of a doctor. (should be more of a collaborator than an authoritarian) I see an interesting parallel with patriarchal and paternalistic ideology and how we approach the title “Doctor”.
As with patriarchal or paternalistic ideology, the title “doctor” holds power, cultural authority, social privilege, and inherent imbalances, due in a large part to a stubborn, complex societal beliefs.
The doctor is put aloft on a pedestal as one who should have the answer or know how to find an answer through selection of the right test. We are taught to defer to their expertise even when the patient is often the best source of information regarding their condition. (In persistent pain, or any painful experience for that matter) *see the BPS framework
While in school I recall that the importance of the title DOCTOR was reinforced regularly and was a “weight of which we should understand the burden”. Patients will be putting their “lives in your hands”. The rhetoric was bolstered through tales of DOCTORS discovering life threatening tumors or vascular abnormalities which were discovered and repaired. These are some of the amazing things that we can do as individuals armed with a wealth of knowledge on what potentially mimics musculoskeletal pain and I do not want to dismiss the importance of this competancy.
The following are 2 problems I see arise with the beliefs which are imbued in these concepts.
1. The student’s ideas and beliefs are shaped in a direction which is unhelpful for a collaborative patient centered approach to care
2. The institution creates an entire conceptual system that they are producing graduates who hold social privilege and power, which then allows them to charge a disproportionately high tuition relative to the earning power of the graduates
Now, I’m not sure you saw part 2 coming, but I believe it is crucial to why some of the fragility narratives remain in my profession. Follow me on this one…
Graduates from Chiropractic college in Canada come out with approximately $120,000 in debt with no business training and are expected to become overnight entrepreneurs (build their own clinic) or enter into a contract with an established chiropractor who may hold onto antiquated ideas that were passed onto them.
Old concepts alert!!!
Since they had to “pay their dues” by paying half of their income in rent when they were associate chiropractors, they must make the new grad do the same. Or some other punitive contractual obligation that “incentivizes the new grad to build their practice”.
Not to mention that the average income of a chiropractor has been falling since the 1990s and estimates are that the average is in the $50,000-$70,000 range. (accurate data is hard to come by, however the most recent peer reviewed data referenced here.)
The situation perfectly sets up the chiropractic marketing/sales folks who have some very lucrative models of care which promote treatment plans and narratives to help practitioners find, and “retain patients” as “maintenance care patients”.
Most of these programs have scripts and narratives to assist with sales, which rely heavily on fear-based tactics to sell “treatment plans” to patients.
I suspect that through trial and error, the marketers have discovered that human behaviour is strongly influence by fear and emotion. If we play to those during our “sales pitch”, we get better “buy in”.
Not to mention that they are marketed to the practitioner as a way to increase the number of patients “they can help”. This helps dispel the cognitive dissonance within the new grad which is created due to the tension between being a DOCTOR and a salesperson. I have a generally positive view of humans and like to believe that most are genuinely trying to help others, so this is not an attempt to disparage chiropractors who buy into this situation. I do believe that, situational pressures come to bear here.
1. The chiropractor is carrying a heavy debt burden
2. They have been primed to expect their hard work to be rewarded with social and financial status.
3. There is an easy cognitive acceptance of a system that will help you, as a practitioner solve both the financial struggle and the goal of “helping” more people.
The biomechanical fragility model will increase how often a patient is treated, and a truly evidence-based model of care will empower patients, thus result in treating them less often. The financial realities of the two options are obvious.
To be clear, I don’t believe that this is always conscious monetary decision that is made by an individual practitioner, and there is a myriad of other cognitive factors involved beyond what I have mentioned here
It is wildly frustrating to be treating people ethically and, in an evidence-informed way while you see another chiropractor using these sales techniques and overtly harmful narratives, especially due to the financially realities baked in. (“Can I afford to pay rent??” vs “Should I buy a new boat??”)
Some chiropractors I know do an incredibly creative job of cognitive gymnastics in order to continue to justify how they continue to treat people when they are exposed to the concept that their practice style/beliefs may be stealing self-efficacy and even sometimes causing harm.
What do we do about all of this???
There are changes required throughout…
The attitudes will need to change…
There are egos that will get in the way
There are financial disincentives for change
It is a monumental hill to climb, yet it starts with one step…
We must accept that there is a problem.
Are we ready for that???
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