The John A. Sweaney Lecture: Vilamoura, Portugal, May 2007, given by Dr John A. Sweaney. Chiropractic: in pursuit of professionalism.

The following is The John A. Sweaney Lecture delivered by Dr John A. Sweaney at the Biannual Assembly of the World Federation of Chiropractic in Vilamoura, Portugal, on May 16, 2007.

Introduction

This brief presentation will touch upon aspects of our development as a profession, with mention of a few relevant pioneers and some other significant contributors of personal acquaintance. The importance of professionalism, the considered attributes for us as practitioners, what we have achieved, and perhaps where we can do better will be briefly addressed (Fig 1).

Fig 1

John A Sweaney, AM, DC, D Sc (Hon), FICC, FACC. Dr Sweaney graduated as a chiropractor from the Canadian Memorial Chiropractic College in 1968 and served as the President of the Australian Chiropractors Association from 1978 to 1980 and as its Executive Director for 12 years. John was President of the World Federation of Chiropractic for 3 years and served on its executive for 12 years. Dr Sweaney currently serves as a Deputy Director on the Federal Government’s Professional Services Review Tribunal, is the National Chiropractic Advisor to the Department of Veterans Affairs, and is Vice Chairman of Chiropractic Education Australia with a responsibility in postgraduate programs in Australia and Japan. John holds an Adjunct Professionship appointment at Murdoch University (Western Australia) and is a Director of Villadsen Health Services and TD Services.

Chiropractic’s professional origins

In terms of pioneers, one would certainly recognize Daniel David Palmer and John Fitz Alan Howard. The essential contribution of Palmer is well recognized, but some may not be quite as familiar with Dr Howard who was an early graduate of DD Palmer’s school and a contemporary of BJ Palmer.

John Fitz Alan Howard founded his own college of chiropractic in the same year that BJ Palmer took over his father’s school. Howard’s college commenced in the building in which DD Palmer originally had his clinic and first school, the Ryan Building in Davenport, IA.

According to historians, Howard expressed his motivations to found a college, which included the following:

To oppose the concept of “one cause, one cure” that was widely held among chiropractors at the time

To emphasize the importance of diagnosis and

To refine the art and to consolidate the scientific components of chiropractic.

These were underpinnings of the birth of the National College of Chiropractic in 1906. The College moved to Chicago in 1908 to secure better facilities including a clinical laboratory, dissection and hospital facilities, licensure, and other advantages to be found in Illinois at that time.

Recognition of educational deficiencies

In North America, the stand-out figure during the period of chiropractic survival who almost single-handedly stimulated chiropractic educational reform was John Joseph Nugent. This 1922 Palmer graduate, who had received sound classical undergraduate education at the National University in Dublin, opposed the prevailing proprietary institutional model of chiropractic education. He campaigned against the proliferation of poor quality programs with abysmal basic science components and virtually nonexistent entry requirements. As Gibbons describes him, Nugent was to chiropractic education in North America what Abraham Flexner had been to modern medical education in that region of the world. Through an independent body that was formed in 1935, the National Council on Chiropractic Examining Boards, Nugent headed a taskforce to study what changes were necessary to achieve uniformity in chiropractic education and licensing. The National Chiropractic Association in 1939 established a Committee on Educational Standards to implement an accreditation process, and this ultimately resulted in the Council on Chiropractic Education. Nugent became the National Chiropractic Association’s first Director of Education in 1941. His work also demonstrated how significant educational standards were in political activity. They achieved both success and failure on different occasions. On one hand, achievements were made in accreditation; however, on the other hand, there was failure of certain colleges to demonstrate that they had attained acceptable minimal standards.

Advancing 50 years later, Prof Bill Walker was one of a significant group of unselfish nonchiropractors whose contribution to chiropractic has been critical to its advancement in Australia. Perhaps at variance to the development in other parts of the world, in Australia, credible educational standards in chiropractic significantly reflect the wisdom and dedication of nonchiropractic academics.

In 1986, Bill Walker presented a memorable paper at the Australian Chiropractic Association Annual Convention. He challenged the Australian Chiropractic Association membership by outlining the fundamental requirements of a profession and a professional. He acknowledged the significance of establishing a 5-year nationally recognized degree program within mainstream higher education. In addition, he reminded us that “to be a professional is more than simply to call oneself Doctor.”

Characteristic components of a true profession

Traditionally, the following are required to be considered a profession:

A unique body of knowledge and specific skills

A recognized credible level of education

A commitment to ongoing educational advancement and research

A genuine contribution to the betterment of society and

A degree of authority and respect that results from the attainment of the other criteria.

Attributes expected of a professional include the following:

The acquisition of a quality education and a commitment to lifelong learning

Recognition of the responsibilities inherent with the authority involved

Adherence to an exemplary Code of Ethics and

A meaningful expression of altruism.

Our progress with respect to “a meaningful expression of altruism” has often been questioned. Yet, without any clamor for recognition, it has and does exist.

Altruism

It is necessary to separate true charitable acts from attention-seeking or marketing exercises that, although they may have a legitimate benefit, hardly satisfy the concept of altruism.

There are some wonderful examples of what the chiropractic profession has done and is doing in the area of altruism. At the 1995 Centennial Congress in Davenport, I chaired a session of inspiring yet humbling presentations reflecting the work of individual chiropractors in Central and South America. Each paper described the efforts of dedicated individuals in isolated locations with little or no financial remuneration or other support rendering effective primary clinical care.

Many colleges, through their outreach educational endeavors, continue to extend chiropractic care to thousands of the world’s less fortunate. I am sure many associations have also made meaningful contributions, for example, the efforts of the International Chiropractors Association in Romania. The Christian Chiropractors Association and other groups have expressed their religious commitment through missionary work combined with chiropractic health care service. Within our Pacific region, there is the Hands-on Health Movement under Dr Dein Vindigni, which couples education with health care within many Australian indigenous communities and other Asian/Pacific locations of serious service disadvantage and poverty. It is a group driven by a commitment to quality endeavors, the latest of which is Project Hope in the Philippines, coordinated locally by Dr Martin Camara. Individually, we all must recognize the altruistic aspect of our professional responsibility in some form; and of course, the reward associated with such voluntary contributions is personal satisfaction.

As Bill Walker suggested in 1986, it could take chiropractic at least 25 years to truly become a profession. We have advanced, but are we there yet?

Some modern contributors to the process

During my chiropractic lifetime, the following practitioners have personally inspired me in their roles as teachers and mentors and also as significant contributors to chiropractic’s professionalization. This small sample has been deliberately selected from among individuals now deceased. Those depicted, for some of you, might not all be familiar faces; however, all were giants within our profession in their time.

Dr Albert Earl Homewood was a 1942 graduate of Western States Chiropractic College. As a native of Toronto, much of his work in chiropractic education was based in Canada where he was on the original staff when the Canadian Memorial Chiropractic College (CMCC) commenced in 1945. He later presided as CMCC President on 2 separate occasions. He was our President at the time of my graduation; and as a student, I admired him as a scholar and author but did not fully appreciate his exceptional contribution to chiropractic education until much later.

As expressed in his published eulogy, he was “one of Canada’s most influential forces for chiropractic education, his passion for elevating educational standards was felt at chiropractic colleges throughout America.”

Dr Henri Gillet, the son of Belgium’s first chiropractor, was a guest lecturer in Australia in 1971. He is regarded as the father of Motion Palpation and as a major figure in the evolutionary understanding of biomechanics in the development from static to motion palpation. He was the founding editor of the European Chiropractor’s Bulletin (forerunner to the European Chiropractic Journal), the initial 20 issues of which were gifted to me and treasured as a young practitioner. Together with his brother Marcel, he also contributed significantly to the establishment of the Anglo-European Chiropractic College.

Dr Fred Illi: In the words of his contemporary, Joe Janse, “Illi’s works are monumental; by far the most brilliant contribution to chiropractic research and representing a clinical premise of tremendous significance.” As he was a close friend of my first chiropractor, I enjoyed periodic contact with this great man and met with him when he came to Sydney in 1973.

Dr Felix Bauer, a 1936 Swiss-born Australian Palmer graduate interned in the BJ Clinic as a spinographer. As a practitioner, Felix’s objective was to always obtain the best possible radiographic image using the smallest possible radiation dosage. Apart from his many radiographic inventions, he single-handedly preserved the chiropractors’ right to retain radiograph licensure in Australia by intensely providing dozens of seminars and workshops for members and personal instruction to hundreds of practitioners. As my chiropractic practice partner and I at the time were not particularly talented radiograph technicians, Felix spent many hours in our dark room until our imaging reflected the impeccable standards he regarded as acceptable.

As many others have done, I could devote an entire presentation to Dr Joseph Janse. Without his inspiration and guidance, I would not have become a chiropractor and certainly would never have persisted in chiropractic politics or have become involved in the elevation of chiropractic educational standards and accreditation.

As a student in 1964, 5 of us from CMCC were generously hosted for a day by Dr Janse, the National College President. For me, a special relationship developed and continued throughout the rest of his life, with memorable times in his company on each of the occasions he visited our region: the Philippines in 1982 and Australia in 1970, 1977, and finally in 1985. Dr Janse significantly influenced the development, survival, and educational establishment of chiropractic in France, South Africa, Australia, and Japan.

The Hippocratic Oath

I have long been fascinated by early translations of the Hippocratic Oath, not the summarized, modernized, and conveniently reconstructed versions that many of us, upon graduation, solemnly committed to or the interestingly varied versions that have accommodated the emergence of surgery and other elements within medicine. Of course, some clauses of the original oath now seem quaintly inappropriate, for example, “I will hold myself aloof from sexual relations with both men and women whether free or slave.”

As often reasonably maintained, other clauses would seem more appropriate to the chiropractor than the medical practitioner, for example, “I will yield to no entreaty to supply a poisonous drug nor give advice to him who demands it and I will swear to the gods to cut no one with stone but to leave this operation to those whose ability it is to do so”. Of course, it is a physician’s oath and one soundly based upon vis mediatrix naturae.

It is interesting to note that 4 of the first 5 items of commitment, expressed in the original translation of the oath, concern education and include the obligation to extend knowledge freely to others. It is also emphasized however that a physician must only teach those qualified to learn and prepared to commit to the same principles of ethical behavior. Generally speaking, most of the principles laid down by Hippocrates still form the basis of ethical health care provider behavior today.

The Declaration of Geneva is a reasonable, modernized adaptation of the Hippocratic Oath; and certainly, the International Code of Ethics that constitutes the ethical obligations of doctors in general should be adapted and promoted by all chiropractic institutions, if it is not the case already. Sadly, because of laws relating to the constraint of trade, the Hippocratic Oath is no longer used for graduates of any Australian medical program.

Modern professional responsibilities

Although most professions enjoy the benefit of community acceptance that a few individuals may exist within the profession’s ranks who are inept, lack integrity, or are simply dishonest, chiropractic does not enjoy such a tolerant or established professional status. As such, we will continue to be damaged by the actions and attitudes of such individuals. Those who are dismissive of acceptable scientific clinical methods or the importance of academic credibility, as well as the dishonest and unethical, seriously tarnish chiropractic’s professional reputation.

The Professional Services Review Tribunal

For the past 20 years, I have served as one of 18 Deputy Directors of the Professional Services Review Tribunal. This Australian Commonwealth Government–appointed body is charged with the responsibility of considering cases raised by the Commonwealth Health Commission against practitioners considered to be abusing their privileges as recipients of government subsidy for health care provision. Essentially, it reviews possible cases of fraudulent activity and overservicing with respect to Medicare payments. For many years, I was able to relax and observe the performance of overstretched Deputies representing a variety of other health care disciplines, particularly general practice, pathology, and radiology.

Inevitably, chiropractors’ activities were questioned by the Health Commission following the government’s extension of the right to refer patients directly to radiologists for examination. I am now organizing tribunal hearings and formally investigating chiropractors in regards to their clinical behavior and billing practices. Understandably, our professional ethics are more openly tested when we are extended professional responsibilities that have a degree of accountability.

Department of Veterans’ Affairs consultancy

In my role as the National Chiropractic Adviser for the Commonwealth Department of Veterans’ Affairs, although there is much that is positive in working to achieve a greater understanding in the health care bureaucracy of the potential contribution of chiropractic, there is also the aspect of advising the Department with respect to the appropriateness or otherwise of a particular chiropractor’s care of veteran patients.

We now enjoy reasonable conditions for chiropractic providers under Department of Veterans’ Affairs regulations. The level of remuneration is acceptable, no prior approval of management plan is necessary, and there is no limitation on treatment. The only factor that threatens the continued increased recognition of chiropractic is the poor behavior of a few chiropractors. Reviewing cases in which many hundreds of treatments have been extended with little sign of progress, or evidence that reexamination has occurred and certainly neither consideration nor any effort to refer, is depressing. Of course, these are not the vast majority of practitioners who service their clients with appropriate dedication and professionalism.

Conclusion

One of the most absurd and damaging expressions bantered among practitioners when comparing their success in the “good old days” was “Those who can’t succeed in practice, teach.” It was an attitude that possibly retarded our maturity by many years.

As practitioners, we are now judged not only by our unique skills but by the quality of our education and our evidence-based clinical outcomes. No longer is the satisfaction expressed by those within the population we serve sufficient to justify our right to provide services, nor does it satisfy those seeking proof of efficacy.

Although other aspects can be identified, undoubtedly, education, clinical research, and ethics are key factors in the attainment of professionalism. If we are to truly become a profession, we must remain committed to the highest attainable standards in each (Fig 2).

Fig 2

Dr Sweaney addressing the Assembly of Members at the WFC 2007 Congress.

Funding sources and potential conflicts of interest

No funding sources or conflicts of interest were reported for this study.