Professional Identity at Los Angeles College of Chiropractic.

OBJECTIVE: The objective of this article is to describe chiropractic professional identity as espoused by the Los Angeles College of Chiropractic. DISCUSSION: Professional identity is a construct that begins formation prior to career selection, can be considered the backbone of health care education, and has been linked to career success. Los Angeles College of Chiropractic's professional identity is shaped by a philosophy of health care that is focused on vitalism, holism, naturalism, therapeutic conservatism, critical rationalism, phenomenology, humanism, and interprofessionalism. Other distinguishing aspects include portal-of-entry professionals with broad diagnostic skills; a focus on spine care; promotion of public-health; and delivery of manual treatments.
CONCLUSION: The chiropractic professional identity at the Los Angeles College of Chiropractic focuses on serving the needs of the people who entrust their health to its graduates and will continue to evolve on the basis of many factors, such as politics, social perceptions, and economic conditions.

Introduction

Professional identity is a person’s self-concept—or how a person thinks of himself or herself—as a professional, based on attributes, beliefs, values, motives, and experiences. Professional identity is formed through a process of professional socialization, which occurs through anticipatory socialization, such as public perceptions of a particular professional role and career selection, as well as experiences in the professional education program, or professional role learning, and continues into professional practice. Professional identity is linked to career success, psychological health, and social adjustment and is particularly important in health care professions, where it has been cited as “the backbone of medical education.”

Professional identity is also related to public trust, in that a clear and coherent scope and purpose must be articulated for the public understand who and what they are trusting. According to Paul Starr:

For any group, the accumulation of authority requires the resolution of at least two distinct problems. One is the internal problem of consensus; the other is the external problem of legitimacy. These are necessary but not sufficient conditions for success. Consensus facilitates the articulation of common interests and the mobilization of group effort, while respect and deference, especially from the more powerful classes, open the way to resources and legally sanctioned privileges.

The chiropractic profession has struggled to develop and adopt a coherent and consistent professional identity, both within the profession and publically, and it has not gained the same degree of authority in mainstream society as other health care professions.4, 5 The objective of this paper is to convey the notion of chiropractic professional identity as embodied by the Los Angeles College of Chiropractic (LACC), which could potentially inform the whole of the chiropractic profession.

Within the chiropractic profession, professional identity has traditionally been tied to the notion of chiropractic philosophy, which, depending on the source, can range anywhere from dogma to practice theories or critical examination of a subject with the goal of better understanding. For the purposes of this discussion, we define philosophy as the study of the fundamental nature of knowledge, reality, and existence. Philosophy is a reflective inquiry aimed at clarifying various modes of thought with no subject matter of its own but rather critical reflections on other subjects. Some within the chiropractic profession refer to “chiropractic philosophy,” which D. D. Palmer originally defined as “the philosophy, science and art of things natural.” It has, however, been argued that “chiropractic philosophy” is a misnomer that implies that “chiropractic has developed a distinct field of philosophy akin to logic, ethics, aesthetics, epistemology, metaphysics and ontology.” Therefore, we feel that it is more appropriate to discuss the “philosophy of chiropractic.”

The word philosophy comes from the Greek roots philo- (love) and -sophos (wisdom) and denotes a systematic pursuit or investigation of wisdom. Although initially this term was applied with the intent of a legal defense, the concepts of chiropractic philosophy became dogma or doctrine, inconsistent with the critical nature of philosophical inquiry and the related concepts of the scientific method. Chiropractic philosophy used in this dogmatic way has historically discouraged critical appraisal, branding as apostates those who dare to question the invariant principles of the fundamentalists. This background is critical in understanding the eventual establishment of competing, nonfundamentalist chiropractic programs, including that of LACC.

We propose that chiropractic philosophy and the philosophy of chiropractic are core to chiropractic identity and have given rise to the diverse and sometimes competing visions of chiropractic that have existed historically and continue to exist today.

Discussion

Historical Considerations

According to author and historian Simon Senzon, D. D. Palmer's Traveling Library and earliest writings embodied science and spirituality, including explanations of magnetic healing, philosophical approaches to health and disease, morals, and detailed meditative practices. Keating describes D. D. Palmer's early chiropractic concepts, including the influences of multiple systems—osseous, muscular, lymphatic, and neural—and the role of inflammation in disease. These early concepts were predominantly mechanical in nature. Consider an early D. D. Palmer comment: “If any part of the body is displaced, including arteries, veins, nerves, muscles, ligaments, bones and joints, it may create friction, which leads to inflammation and disease.” The supremacy of the spine did not preclude the inclusion of extraspinal influences, including those of the connective tissues. B. J. Palmer also acknowledged the importance of extraspinal influences, including lifestyle habits such as exercise (Fig 1). D. D. Palmer’s concepts evolved considerably over time.8, 11 He did not coin the term chiropractic subluxation or author the inaugural textbook of the profession; those were attributed to Oakley Garfield Smith, Solon Massey Langworthy, and Minora C. Paxton in their 1906 primer, Modernized Chiropractic.9, 12 More metaphysical, religious concepts were added later and were offered to provide legal protection to chiropractors under the religious exemption clauses in many medical practice acts.9, 11

Fig 1

B. J. Palmer’s gym.

The separate and distinct nature of the profession could be due in part to D. D. Palmer's concepts of universal intelligence and innate intelligence, as well as the hypothesis that chiropractic adjustment could unite the spiritual and physical, combined with his “confusion about philosophy and its role.” Many distinct concepts commonly associated with the profession were outgrowths of legal defense tactics in various court cases, such as the landmark Morikubo case. In 1907, Shegataro Morikubo, DC, was charged with unlicensed practice of medicine, surgery, and osteopathy. The successful defense of Dr. Morikubo legally distanced the profession from either medicine or osteopathy and was based largely on proposing that chiropractic has a unique science, art, and philosophy; similar arguments were used successfully in subsequent legal cases. D. D. Palmer engaged attorney Tom Morris to represent Dr. Morikubo on behalf of the Universal Chiropractors' Association.13, 14 Morris’ defense strategy, beginning with the Morikubo case, created a philosophy of chiropractic (ie, a set of principles) that would become standard in legal defense.13, 14 Ian Coulter elaborated on this topic in his book, Chiropractic: A Philosophy for Alternative Health Care:

To establish itself, chiropractic was forced very quickly to develop an identity that would distinguish it from other practices such as osteopathy. To do this, it rapidly became focused on the metaphysical and philosophical elements of the paradigm, which soon became dogmatic and ideological. Chiropractic was also very soon under attack from medicine, with chiropractors being prosecuted for practicing medicine without a license. A major defense was to claim that chiropractic was a distinct branch of the healing arts. Since the ailments they treated were not distinct, and neither was the therapy, the major distinction became the “intent” for which they have the adjustment. Lacking a scientific rationale for this so early in the development of the paradigm, chiropractors turned to so-called chiropractic philosophy, metaphysics and dogma for their legal defense.

The prevailing legal and political landscape, and Palmer's former students forming competing narratives as to the nature of the profession and opening new chiropractic colleges, provoked D. D. Palmer and his son, B. J. Palmer, to write and teach with more of a focus on philosophy, the spine, and supremacy of the nervous system, shunning earlier multisystem contributions and explanations of health and disease. According to Phillips and Keating, “Although D. D. Palmer railed against the combination of chiropractic and other drugless methods, the ‘mixing’ of so-called alternative healing procedures and professions (chiropractic, naturopathy, osteopathy) seems to have developed rather rapidly after Thomas Storey founded his school.”

The founder of LACC, Dr. Charles Cale, earned his chiropractic degree in 1908 or 1909 from Storey’s Chiropractic School & Cure in Los Angeles. Cale was also licensed in naturopathy (in 1909 or 1910) and trained in osteopathy (ca 1916) at what is today the University of California at Irvine School of Medicine. Founded in 1911, 4 years after the Morikubo trial, LACC was the product of several coexisting philosophical constructs that emerged from within the profession and were not entirely concordant with those promulgated by D. D. and B. J. Palmer. At that time in California, “philosophical diversity plaguing efforts to bring unity to the profession” was observed. However, the early identity of LACC was more consistent with D. D. Palmer's pre-Morikubo precepts and less so with the later philosophical ideals of D. D. and B. J. Palmer. Although messaging touting both “pure, specific, unalloyed” and “straight” chiropractic as well as a “broad-scope philosophy of instruction” appeared in early LACC catalogues, the college’s founding purpose was recorded as “the teaching of chiropractic, anatomy, histology, gynecology, pathology, obstetrics, bacteriology, chemistry and toxicology, physiology, general diagnosis, hygiene, and naturopathy,” and Cale’s “‘mixer’ tendencies” were “cemented” into a broad-scope perspective through LACC’s merger with Charles Wood’s Eclectic College of Chiropractic in 1924.

Los Angeles College of Chiropractic’s Philosophy of Chiropractic

The LACC is 1 of 3 colleges that now comprise Southern California University of Health Sciences (SCU). The LACC has endeavored to foster a chiropractic professional identity consistent with its overall philosophy of healthcare combined with the additional characteristics of astute diagnostic skills, expertise in the spine and neuromusculoskeletal conditions, a public health perspective, and excellence in manual therapies. Los Angeles College of Chiropractic’s philosophy of chiropractic was eloquently captured in a 1994 article that described the fundamental elements of vitalism, holism, naturalism, therapeutic conservativism, and critical rationalism. We assert that these fundamental elements remain central to the LACC philosophy of chiropractic. Additionally, the philosophies of phenomenology and humanism, which were “experimental” in 1994, have since accumulated sufficient evidence in the literature to be included in the LACC’s philosophy, along with the element of interprofessionalism.16, 17 Each of the elements central to the LACC philosophy of chiropractic is defined as follows:

Vitalism: The inherent capacity of the body to heal itself, which leads to the view that the health care provider is a facilitator of healing rather than he sole source of healing.

Holism: The individual is an integrated unit consisting of the body, mind, spirt, interpersonal relationships, physical environment, and the whole of nature. The purpose of health care is to maintain this integrity; when a person is sick, care should restore all aspects of this unit, and not just treat isolated symptoms or diseases.

Naturalism: A preference for natural remedies where appropriate.

Therapeutic conservatism: The best care is the least amount of intervention necessary, and the aim of therapeutic intervention should be directed at the root cause of the condition rather than symptoms alone whenever possible.

Critical rationalism: The scientific method is applicable to health and health care and should provide the knowledge base for clinical practice.

Experimental philosophies: When the Phillips et al. paper was published in 1994, there was a notion that the scientific or biomedical framework may not be sufficient for explaining all health-related phenomena and that other, experimental paradigms such as the experiential philosophies of phenomenology and humanism should be explored. Twenty-two years later, critical rationalism, in the form of the peer-reviewed literature base, has provided evidence that phenomenology and humanism have now emerged and are no longer experimental.17, 18, 19, 20

Phenomenology: People experience phenomena subjectively, in personal ways, such that the same experience can and will affect different people differently. Two people with the same physical characteristics, health history, and social demographics may present with the same type of acute, localized, non-specific low-back pain yet have 2 very different outcomes because one may experience the back pain as a fearful condition over which they have little control whereas another may experience it as something to work through and overcome.

Humanism: There is more to health and illness than pure biology and pathology. Personal and human aspects are critical to optimal health outcomes; therefore, health care providers must care for patients in a compassionate and humanistic manner.

Interprofessionalism: Multiple providers with different professional backgrounds or licensures collaborate to provide comprehensive person-centered health care. The World Health Organization has cited interprofessional collaborative practice as strengthening health systems, improving health outcomes, and allowing health care professionals to deliver the highest quality of care.

Other Aspects of the Los Angeles College of Chiropractic’s Chiropractic Professional Identity

The components of the LACC philosophy of chiropractic are the same as those of SCU’s philosophy of health care. Although developed originally as a college that trained doctors of chiropractic and naturopathic medicine, this philosophy is consistent with the philosophy of all SCU programs and core to each program’s identity. Although these values are core to professional identity, they do not comprehensively define one discipline’s professional identity. Other aspects are involved and differentiate a doctor of chiropractic from a doctor of acupuncture and oriental medicine, for example. For chiropractic at LACC, these additional, profession-specific traits include serving as a portal-of-entry professional with broad diagnostic skills; a focus on spine care; promotion of public health; and delivery of manual treatments.

Scope of practice for doctors of chiropractic in the United States is defined by each state. Although chiropractic scope of practice can vary widely between jurisdictions and is dynamic, the overarching theme is a broad diagnostic scope of practice combined with a more narrow scope for examination procedures and an even more narrow scope for therapeutic procedures. The Council on Chiropractic education requires accredited colleges to train doctors of chiropractic to “practice primary health care as portal-of-entry provider for patients of all ages and genders.” Although doctors of chiropractic cannot always function as primary care or portal-of-entry providers in all jurisdictions because of the realities of acceptance and reimbursement by entities such as payers, employers, and schools, the training and ability to serve as portal-of-entry providers are central to the LACC chiropractic professional identity because early detection and referral for health conditions that are not optimally managed by the various therapeutic approaches offered by chiropractic doctors are critical for optimal relationship-centered care and outcomes. In the role of a spine care specialist, a doctor of chiropractic may expect to encounter serious pathology as a cause of spinal pain in 1% of patients, which for a busy practitioner could equate with several cases per year, making effective diagnostic skills indispensable.

Chiropractic education and training, although broad enough to support the diagnostic scope of practice, is particularly focused on diagnosis and conservative management of the spine and neuromusculoskeletal systems. Health of these systems is something that unifies all doctors of chiropractic. Some chiropractors may choose to receive postgraduate education and specialize in areas such as nutrition and internal medicine, but spine and neuromusculoskeletal care is core to chiropractic education and general practice. At the World Federation of Chiropractic Biennial Congress in June 2005, “spinal health care experts in the health care system” was unanimously supported as the most appropriate public identity for the chiropractic profession. This aspect of the chiropractic identity appears fitting because, according to Nelson et al, “The chiropractic patient population consists, almost in its entirety, of persons with musculoskeletal pain complaints, the overwhelming majority of which are spine related. A small subset, approximately 5%, of patients have headache as a primary complaint. Any reasonable estimate would place the percentage of chiropractic patients with somatic pain at >95%.” This is not to say that the chiropractic profession must be defined by its existing patient base; even if the public and other health care professionals were to view doctors of chiropractic differently, the conditions for which manual therapies are most effective are somatic.

As conservative spine and neuromusculoskeletal experts, doctors of chiropractic may also embrace a public health approach to care. According to Murphy et al, “Public health is ultimately about self-empowerment and teaching people how to take care of themselves, with an emphasis on prevention and health maintenance.” Some believe that chiropractic care ultimately equates with a patient receiving adjustments each week for a lifetime. Although this may be the approach of a few practitioners, the LACC approach is different. Instead, LACC promotes a focus on prevention, use of naturalistic and minimalistic treatment principles with an appropriate and finite endpoint of care, and promotion of healthy lifestyle habits. Minimizing treatment frequency is not new to the chiropractic profession. B. J. Palmer bragged about only needing to administer 1 to 2 weeks of care in advertisements published as far back as 1902 (Fig 2). Furthermore, support for or opposition to common public health practices should be based on evidence rather than dogma. To demonstrate its dedication to public health, LACC has institutionally funded student memberships in the American Public Health Association for more than 10 years as a means of exposing students to and supporting the United States’ largest and most influential public health association.

Fig 2

B. J. Palmer advertisement on treatment frequency from 1902.

Some subsets of the chiropractic profession have defined the profession by its focus on examining and adjusting the spine, specifically chiropractic vertebral subluxations. Intraprofessional feuds have raged over just how exclusive this focus should be. Much like the evolution of the subluxation concept, the approach to health promotion, disease, and injury has evolved at LACC.

Spinal manipulation (SM) is offered by a number of professions, but chiropractic doctors have been most closely identified as providers of this procedure, which has been a distinguishing characteristic of the profession since its inception.25, 27 Ninety-four percent of SM for which reimbursement is sought in the United States is delivered by doctors of chiropractic.26, 28 Keeping in mind that SM is a primary treatment approach, the development of exceptional palpation skills is a fundamental diagnostic proficiency taught at LACC. Progressively, LACC students are exposed to hands-on, manual skills classes and ultimately spending a minimum of 585 hours or 17% of nonclinical instruction hours in classes dedicated to palpation, spinal analysis, and manipulative procedures. The generally accepted goal of palpation is to identify the source of the patient’s problem, such as the level of spinal restriction, and to determine where and what type of SM or manual therapy should be employed. Consistent with evidence-informed clinical practice, LACC has also stressed the importance of when not to adjust the spine, based on patient history, examination findings, and biopsychosocial considerations such as self-efficacy. This does not refer to merely avoiding SM in the presence of red flags or when contraindications to care are identified; rather, despite the central importance of SM, it is seen as an important component of patient management in many, but not all, patient encounters.

Chiropractic Professional Identity: Evolution

Chiropractic professional identity was influenced not only by the values and beliefs of practitioners, but also by their experiences and other external forces that influence their self-concept, values, and beliefs. In the formative years of the chiropractic profession, D. D. Palmer sought a new approach for maximizing health, and he initially did so in a way that could be described scientifically27, 29 and embraced a multisystem approach. Later, the legal pressures from the Morikubo trial, among other factors, influenced the Palmers to shift their teachings to a narrower focus which was represented as distinct from medicine and osteopathy, hence focusing on a distinct “chiropractic philosophy.” This distancing was a pragmatic strategy that may have preserved the profession, but it also undoubtedly had the effect of creating a separatist component within the chiropractic professional identity.

The separatist mentality also was reinforced by prevailing political and social attitudes and pressures, given a climate in which chiropractors were arrested for practicing medicine without a license and later subject to discriminatory practices by the American Medical Association Committee on Quackery. As recently as 1998, health care scholars have documented lack of acceptance of chiropractic within the mainstream medical community: “Although the American Medical Association no longer prohibits its members from consulting with chiropractors, especially because it was found guilty of conspiracy in this regard, chiropractic’s size and power have not translated into complete acceptance.”27, 29

In 1999, Ian Coulter wrote:

The intellectual journey over the past 20 years has led the author to the conclusion that chiropractic and, by implication, the alternative health-care providers, do provide a different philosophical way of conceptualizing health and illness. It is a philosophy that leads to a distinct way of interacting with the patient and of thinking about outcomes. Given the rather wholesale retreat of medicine from philosophy in the twentieth century, this perspective has largely been preserved as a living philosophy by the alternative providers. While it was a perspective that characterized medicine for much of its early history, and survives in areas such as holistic medicine, its loss had serious consequences for health care.

Recently, health care has continued to evolve, with increasing trends emphasizing cost-effectiveness, patient satisfaction, and improved clinical outcomes. Factors such as increased medical specialization and subspecialization, increasingly complex patient needs, and shortage of health professionals have additionally inspired a move toward collaborative, patient-centered interprofessionalism. The National Institutes of Health allocate substantial federal funding to chiropractic research. Organizations such as the Academy of Integrative Health and Medicine and the Academic Collaborative for Integrative Health advocate for a new paradigm of health involving comprehensive person-centered care and welcome all professionals who share this vision. Health care consumers have continued to seek and demand chiropractic care, which is an included benefit under Medicare, many private insurance companies, the Department of Defense, and the Veterans Administration. Although professional tensions continue to exist, shifts in the health care climate and attitudes of other health care professionals influence the prevailing chiropractic professional identity such that a key component of chiropractic professional identity at schools such as LACC is one of interdisciplinary collaboration versus professional separatism. This may, in turn, result in various types of health care providers, whether mainstream or alternative, embracing different philosophical ways of conceptualizing health and illness.

No single component alone can define LACC’s chiropractic identity. Professions including neurosurgery, orthopedic surgery, physical medicine and rehabilitation, physical therapy, osteopathy, and massage therapy offer spine and neuromusculoskeletal care; some even offer conservative, manual therapy. Practitioners, including licensed acupuncturists, doctors of naturopathic medicine, Ayurveda certificants, and increasing numbers of medical and osteopathic physicians, embrace vitalism, holism, naturalism, therapeutic conservatism, critical rationalism, phenomenology, humanism, and interprofessionalism. Many specialties promote public health. Thus, it is not any one of those aspects that constitutes chiropractic identity for LACC; rather, it is the combination of all of these factors employed dynamically by each doctor of chiropractic that defines our professional identity.

Limitations

This commentary provides the opinions of the authors and may not necessarily capture all of the features or represent all opinions of the identity of LACC. More detailed qualitative research is needed to measure whether our description matches what is delivered by the LACC doctor of chiropractic program and the perceptions of all faculty members, students, and alumni.

Conclusion

The LACC professional identity will continue to evolve based on the many factors, such as politics, social perceptions, and economic conditions, that have influenced it in the past. Most notably, perhaps, is the factor over which we have the most direct control: our own actions as professionals. We have historically been a divided profession, perhaps because of the necessary professional separatism we had to adopt to keep the profession alive, but we should continue the dialogue on matters such as chiropractic professional identity and never forget that we are here not for our profession or for ourselves, but for the people who entrust us with their care.

Funding Sources and Conflicts of Interest

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

Contributorship Information

Concept development (provided idea for the research): J.S.

Design (planned the methods to generate the results): J.S., M.N.K., R.R.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): J.S.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): J.S., M.N.K., R.R.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): J.S., M.N.K., R.R.

Literature search (performed the literature search): M.N.K.

Writing (responsible for writing a substantive part of the manuscript): M.N.K., R.R.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): J.S.

Practical Applications

This paper describes professional identity at LACC.

Given the historical fragmentation of the chiropractic profession, this information may serve as useful dialogue for resolving intraprofessional differences.

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