The McAndrews Leadership Lecture: February 2016, by Dr Greg Kawchuk. Putting the "Act" Back in Chiropractic.

The McAndrews Leadership Lecture was developed by the American Chiropractic Association to honor the legacy of Jerome F. McAndrews, DC, and George P. McAndrews, JD, and their contributions to the chiropractic profession. This article is an edited and truncated version of the McAndrews Leadership Lecture given by Dr Greg Kawchuk on February 27, 2016, in Washington, DC, at the National Chiropractic Leadership Conference. This was the second McAndrews lecture in this annual series.

You might ask, what would I know about the McAndrews family and their impact on the chiropractic profession. When I was a young chiropractic student at Canadian Memorial Chiropractic College from 1986 to 1990, there was no Internet. To communicate with loved ones, we wrote letters. So getting mail was a big deal. This meant that we found out about what was going on in chiropractic by mail. Every month we would receive some magic in the mail called Dynamic Chiropractic. From that newspaper, we would read about different treatments, opinions from thought leaders, far away conferences, and the tools we would need for practice. We would also read about the unfolding saga of the Wilk trial, where 5 chiropractors sued the American Medical Association for their antitrust efforts to contain and eliminate the chiropractic profession. This lawsuit could never have happened without George McAndrews, a lawyer who took the case, and Jerry McAndrews, DC, his brother, who had unmatched passion for the profession. As the years went on, the story of the Wilk v. AMA trial unfolded like a spy novel, and we could not wait to read what was going to happen next. For a young student, reading about the trial and the McAndrews brothers would forever open my eyes to the realities of chiropractic practice. From that point on, legitimizing chiropractic would never be just a matter of educating people about chiropractic or producing more chiropractors; it was also about overcoming overt bias from individuals as well as powerful institutions. The outcome of the trial was profound for me and those in Canada. It showed that chiropractors could stand up to those who oppress chiropractic and win.

I am honored to have been invited to give the second annual McAndrews Leadership lecture.1, 2 This presentation will not be a historical account about leaders from our past, but more of a talk about leadership itself—who, or what, will lead the chiropractic profession in the future. So back to the earlier question: “What is it that a researcher can offer on the topic of leadership?” Let me ask you a question. How many of you would like to attend a seminar today on a treatment technique—something that you can do with your hands? Lots of people. Okay, now, how many of you would rather attend a seminar on health policy or practice guidelines? Not so many!

Why is this? Why would chiropractors prefer to go to the technique seminar or the practice management seminar and not attend a lecture on guidelines or public health? Perhaps too often we have been told that seminars need to give us content that we can use on Monday morning. Sure, who does not want information they can use right away? But is there really some undiscovered miracle technique waiting out there that will transform chiropractic for all of us? Or could it be that the best chance we have to improve our profession, to be leaders in our profession like the McAndrews brothers, is to open our minds to new ideas? Now, do not get me wrong. Keeping our technique skills up is important and necessary, but it is not going to lead our profession to be better in the next decade. That is where the title of my talk comes into play.

“Chirostatic.” Are you “chirostatic?” Like kids learning how to play musical instruments, we as a profession have a bad habit of practicing the things we are already good at—the little song we can already play instead of working on the thing that really needs attention and hard work. Sure, we always need to hone our technique skills. However, it is time to consider that we need to invest in other areas if we want to leave this profession in better shape than when we each started to practice. We need to be as excited about going to a seminar on public health as we are about learning what color we should paint our waiting rooms.

So instead of being “chirostatic,” we need to be “chiroactive”—to learn about new things that improve care for our patient and then take those new ideas and make them work in our practices and our profession. We need to make chiropractic bigger and better than its founders could have ever imagined. What we need to do is to put the “act” back in chiropractic. This may sound good, but really, why should you care? Why not just keep going to technique seminars and practice-building boot camps? Well, as a university professor and the Research Chair of the World Federation of Chiropractic, I am fortunate to have the opportunity to speak to chiropractors over the world—people in different countries, associations, schools, and organizations. From my unique perspective, it is clear to me that we have a global crisis in chiropractic because we are not paying attention to innovation, including new ideas from outside of our profession that can benefit our patients.

For example, look at the dentistry profession over 100 years ago. It started without aseptic technique, without anesthetic, without knowledge of the role of bacteria in gum disease. Painful tooth extractions were mostly what dentists did. Now think about all the new ideas adopted by dentistry in the last 100 years, like fillings, crowns, and dental hygiene. Yet, despite all these innovative ideas that changed dentistry, the profession moved forward. There were no breakaway groups of dentists that decided they were going to treat only the upper teeth and not the lower teeth. Think about that. It is remarkable how dentistry evolved with new developments, yet they did it consistently and as a group. As a result, going to the dentist means nearly the same thing for people all over the world, for the betterment of everyone.

Now let us look at chiropractic in the same way. Take a look at a treatment room from 100 years ago and one from today. We see the same treatment table a century later. We still have the same nerve chart on the wall. We even see the same decorations. Is this the culmination of our progress over the last 100 years? Have there really been no great ideas worth adopting into our profession over that amount of time?

I am not saying we need to change for the sake of change. But can we do better than this? Certainly, what has transpired historically in our profession was important. We would never have survived this long as a profession if historic chiropractic was not powerful and impactful. But right now, do we embrace innovation for the benefit of our patients, or do we spend our careers practicing with the same information that we obtained at graduation? Who in cardiology can still practice the way they did when they graduated 10 years ago? If they did, they would be unsafe. Why should chiropractic be different?

Now when I say this, chiropractors think that issues in accepting innovation only happens with “those other guys.” And who are “those guys?” It may be the chiropractors in the black and white photos taken “back then?” Nope. They are not the problem because they probably left practice decades ago or are no longer with us. So, who is the problem? It is likely you. These days, things are moving so fast that if you are even 3 years out from graduation and have not made a major upgrade in the way you practice, you are a dinosaur—a chirosaur. You are “chirostatic.”

If you do not believe me, take a look at what the fast food chain McDonald’s has done. How did this company achieve global dominance? They have a standard product. You may not like it, you may not eat it, but for the most part, it is a standard product that people know and expect to be given when they walk into any McDonald's in the world. You do not go around the world and find a McDonald's that serves kebabs. Everyone in McDonald's is on board with delivering a product of high quality that is consistent from one location to the next. And yet for all that consistency, McDonald’s is still capable of innovation and big change. They improve and add choice to their selections. They embrace new ideas, and the ones they embrace, they use all over their empire to move together in a consistent way so that customers all over the world have the same great experience that continually is improving.

The lesson here, a consistent product, does not mean serving the same menu from 50 years ago. The product may be a standard all over the world, but it has also been allowed to keep evolving as innovations occur in nutrition and public preference. Not only is evolving consistency good for patients, it is also good for the chiropractic profession. Look at the jurisdictions in the world that have evolved in a consistent manner and you can see where chiropractic flourishes. Places where there is 1 association, not 7. Places like Denmark, Switzerland, Canada, and Iran. It is not a geographic thing. Nothing is different about the people in these countries compared with here. Chiropractic does better in these places because they have realized that as a starting point, chiropractic cannot be everything to every chiropractor. They created consistency first and then allowed the profession to evolve from that base. Where have we ever been successful trying to encompass all possible definitions of the profession as a starting point?

It is important that we as a profession look at big ideas, at innovation, because of the impeding expectations of something called “pay for performance.” Today, many of you have to call ahead to get approval to be paid for treating your patient. Yet, no matter how your patient responds to your care, you still get paid. That approach is going to be extinct in the next few years. The future is, you will be paid on your results. You will get a report card that tells you if you are over- or underperforming compared with your peers—if you are not meeting the community standard or the scientific standard, you are not going to get paid. If you do not hit that standard, then your paycheck is gone.

Therefore, it is perilous to ignore new ideas that advance the chiropractic profession because the world keeps advancing around us. We cannot afford to live in a history bubble, to ignore public health or clinical guidelines and instead keep doing the things we are already good at because the world is changing around us at a frantic pace. What is fundamentally different is where these innovations are coming from. They are not coming from a founder, a guru, a practice management consultant, or a YouTube personality. Certainly, there was a time when we needed strong opinions from charismatic leaders to carry the flag forward. But these people are not the leaders anymore.

You may ask, “Who is the new leader?” The answer is that the new leader is not a person. The new leader is a thing. The new leader is data. This is a huge shift. Now more than ever, data shape the opinions and the decisions in every aspect of our life. How we pick a restaurant, or a flight. And, of course, how our patients pick a chiropractor. We are already there.

Now you may be thinking. “Aha! Now I see where this is going. This is just another lecture on evidence–based care.” No, it is not. First, ask yourself which of the following is in our best interest: should we support a historical version of chiropractic at all costs or should we allow the profession to evolve based on the best information as it becomes available? Is it chiropractic’s destiny to support a historic view of what the profession was? Or is it our destiny to evolve and to change with what is best for the patient? When you take your kids to the historical park, do you want the best current version of chiropractic standing beside the blacksmith?

However, while data gives us the ideas of where we can go, the data itself cannot lead. Data is amoral. It has no agenda. It has no direction. It still needs people to be able to push ideas forward. The difference is there are no longer only a few people, a few leaders, who can access the data. Data point us in the direction we should go; we all get to have a compass now, not just a few ship captains. We all have access now. Data access today makes possible leaders out of all of us. Today, we each have an opportunity to be a leader each and every day because we have the access to information that once was held only by people in power. But now that we have equal access to the content, the playing field is level. We can all be leaders of the profession.

So, what should we do with this idea that each of us leads the profession? Perhaps the most important consequence is that our access to data can bring us together as a profession. While we can try to use data to attack people with opposite views, data can also illuminate unique opportunities to bring us together. How? Well it is not only about having access to the data, it is about getting to know it and getting intimate with the data. Because if you know the data, you can see things that really make the future exciting for all chiropractors.

So here are some things that I see. Not because I am a researcher, but because I am swimming through the data and taking a good look as it goes by. And you can do the same because now it is all there for you to see. So, let me describe to you a future where data can lead our profession, not only to create consistency in our product, but to build on that and expand our product more than any single guru could ever imagine.

For example, treating pain can be the great unifier of our profession. Think about it. Pain as it stands right now divides our profession. Some in our profession feel that treating a patient’s pain is noble. Alternatively, others suggest that we should focus on treating the “whole” patient and downplay pain. Well, here is another way of looking at this. A way that removes the division about pain and that reveals itself through data—data we all have access to as the new leaders.

If you remove pain from a person’s life, not only does it improve the immediate quality of life, the effect of reducing pain also helps control other comorbid problems like headaches, insomnia, anxiety, depression, and others. So really, the best thing you can do for the wellness of your patient is to get them out of pain. Think about that and about the best way you know in practice today to create wellness for a patient. Real wellness that patients report, not wellness you tell them they have. Now stack that up against the benefits you can achieve in a person’s life if you control their pain. I challenge you to think of another intervention you can apply as a chiropractor that will have a bigger effect on a person’s wellness than reducing their pain. By controlling your patient’s pain, you are providing the most impactful treatment to improve the health and wellness of your patient. As cool as that idea is, as transformative as that idea can be, notice that it did not come from a guru, from a green book, or from a weekend technique seminar. In fact, this idea did not come from me either. This idea—that removing pain is the best way to increase wellness—is one that comes from data, data we all have access to. The data that empower all of us equally. The guru is dead. The best ideas in the new future are coming from data.

Now some people may think that this is a limited approach. No matter how many times I say how data will take us in new direction that no guru could have even imagined, people hear the word “data.” They hear the word “evidence.” They revert to their fear that by only treating pain, there will not be enough business to earn a living and that their practice would dwindle. I say that the data suggest otherwise. New scientific discoveries are expanding our scope of practice more than any of us could have ever imagined even 10 years ago. Right now, if we only treated pain and did a good job of it, we as a profession would be swamped. Then, add in the ability to improve other comorbid circumstances. Then add in new areas where we are having a huge impact like conditions of the chest wall. Think about that. We have been treating this “back” here all these decades and then someone decides to collect data on the opposite side of the body and then suddenly there is a wide open area for us as clinicians, to help patients—the chest wall. There are ways we can help patients on the front of their bodies. All this has been made possible because of data. So, we cannot imagine how big this profession can get if we put our trust in developing more data and using more data. We do not have to dream about new areas of practice; science is taking us there.

Here are some data from my lab that have the potential to profoundly change the scope of your practice. It starts with being able to give a really good explanation about how the adjustment works. Can you give a clear explanation right now? If you cannot, that may be a problem for our profession moving forward. So, if I have a goal, it is to give you an explanation for what happens with an adjustment and then show you how that explanation might expand practice. The data come from a study by Arnold Wong, who is a professor at Hong Kong Polytech. The study itself came out of a frustration, which is that a systematic review comes out that says manipulation is great for back pain. But the next week, another review comes out that says the opposite. Which one is correct? Let us think of an example. There are two women who are approximately the same age. They do the same thing, raking leaves, and they both get back pain afterward. Now you may have a good idea about what might be happening when each comes into your practice for chiropractic care. The first woman is lucky. You treat her and in 5 days she gets better. The second woman, however, does not respond anything like the first and they both had exactly the same treatment. So, the second woman decides to do some self-care. She does some reading and buys a brace. That does not work so she buys an inversion table. Then that does not work so she gets some surgery. That does not work, so she tries opioids. Years later, she is still in pain. How can this be for two people who described their problem in the same way, presented with the same findings, and had the same exam results?

Back pain is not caused by any single factor, but is due to a set of different problems that are challenging to identify in any given person. The study by Dr Wong indicates that some people are responders to spinal manipulation and other people are not. This is what we had seen in clinic all the time, but could not put our finger on it. To figure this out, our study used a special device to measure the stiffness of the back before and after treatment. In subjects who told us that adjustments helped them, we saw that they had an immediate decrease in spinal stiffness, in one treatment or maybe two. In contrast, for the people who told us that adjustments did nothing for them, their stiffness measurements did not change, but remained at a high level, even after multiple treatments. Not only did we see this in spinal stiffness, we actually saw this same reaction in muscle control and disk hydration—in people who reported being helped by manipulation, muscle activity and disk hydration returned to normal levels, but only in the adjustment responders.

These findings tell us that manipulation is more than a nonspecific effect, such as the laying on of hands or talking to our patients, the things that some feel explain our success. In our study, we used the same chiropractor doing the same treatment on everyone. So, if the chiropractor simply got people better by the laying on of hands, then everyone would have the experience. Our study showed that manipulation in responders is physically changing these people. In some people, manipulation can significantly and immediately alter stiffness, muscle activity, and disk diffusion. Biomechanics, neurology, and biology. But there is a caveat. Not everyone has this physical change with manipulation, which is the same for any intervention. Nothing works for everyone all the time. Because of the data, we think we might know why some people respond to adjustments and not others.

Think of these data from a practice point of view. Some people might say: “Nope, seeing only those who respond to manipulation is going to kill my practice.” But think of this perspective. Imagine you have a crystal ball that can show patients the best treatment for them in the coming months. That crystal ball can be chiropractic. Manipulation may actually be a fast and cheap way for patients to find out what works, instead of them having skulk around from one profession to another working it out for themselves. We could stop trial-and-error shopping by patients and help steer people to where they need to go sooner and cheaper. That is the beauty of this finding. This is not about chiropractic. It is a scientific discovery that may allow us to better triage patients, and we can be the profession who embraces this idea or not.

Why is this important? Well one of my most memorable moments in practice happened to me with an older gentleman. One day I examined him and came to the conclusion that I could not help him. I told him this. I can remember being scared to tell him. I feared I would disappoint him by not offering something. But I told him that I could not help him and that I would send him to someone who I think could do better for him. His response? He put a $100 bill down on my desk then said, “You know, you are the first person to say that and to save me the time of not having to go through this again and again.” So, keep that in mind and imagine the good will we can create in our profession if we can help people decide what is best for them even if it might not be chiropractic, and that does not even touch on how we might help manipulation nonresponders.

Another important implication of our study of those who respond to manipulation is that it explains why we see mixed results in practice. It also explains why science can have mixed results. What if an experiment has a really small group of responders and a really big group of nonresponders? If that happens, I get negative study results. But what if I run the same study another time but have fewer nonresponders and more responders? Now I get a positive study. While this is a problem for scientists, understanding this is also a huge advancement for the profession. Why? Because it explains what has happened in our profession for decades. There are people who think chiropractic “works,” whereas others think it “does not work.” These data give us an opportunity with patients, insurers, government, legislators—everyone. When in history do you get to tell everyone they were right all along? To the professions and scientists who said chiropractic did not work, they were right. But the professions and scientists who said it worked were also right. It all depends on who in your practice or in your scientific study is a responder or a nonresponder. This is the best win-win situation. This study gives us the chance to say that all of us, our supporters, our detractors, were each right all along; we just have a new perspective on it now.

In conclusion, chiropractic is more than doing things with our hands. Chiropractic must become a profession that does things with innovation, with new ideas that are best for our patients, not “chirostatic” ideas that are best for us as clinicians. Let us put the “act” back in chiropractic. The “act” is not just treating patients with your hands; the “act” is thinking about new ways for the profession to grow. The “act” is about using data to lead our profession. That “act” is now in your hands. It is not the “act” created by a founder, by a guru, a president, a representative, or a seminar celebrity. The profession is in your hands, not only because of how you use your hands with patients, but because of how you use your hands to access the information that can transform this profession. Information that allows you to “act” on Monday just as much as any technique seminar. This is what you need to pay attention to on Monday morning. Put the “act” back in chiropractic. Thank you.

Funding Sources and Conflicts of Interest

This lecture is sponsored annually by the American Chiropractic Association. The annual speaker who provides the McAndrews Lecture is provided travel costs and an honorarium by the American Chiropractic Association. No conflicts of interest were reported for this paper.

Contributorship Information

Concept development (provided idea for the research): G.K.

Design (planned the methods to generate the results): G.K.

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

Writing (responsible for writing a substantive part of the manuscript): G.K.