The John A. Sweaney Lecture: Washington DC, March 2017, Given by Dr Geoff Outerbridge. Our Highest Level of Contribution: Doing the Right Thing, the Right Way, for the Right Reason.

The following is The John A. Sweaney Lecture delivered by Dr Geoff Outerbridge at the Biannual Meeting of the World Federation of Chiropractic in Washington, DC, on March 14, 2017.

Introduction

A wise chiropractor once told me, “Every time you learn something, think of how it will benefit your patients.” I have kept this amazing advice in my mind throughout my education and career, and it has served me well over the years.

After I graduated from Canadian Memorial Chiropractic College, I wanted to treat as many patients as possible since I knew there was much to learn from them. For 8 years, I ran a multidisciplinary clinic in Ottawa, Canada, until I was introduced to Scott Haldeman. His unwavering vision and dedication to founding World Spine Care (WSC) was incredibly inspiring. At that moment, I gave up my professional life as I knew it in order to join him in an amazing adventure—one that would help those in underserved communities gain access to high-quality spine care.

During my first visit to Botswana, Africa, Scott’s wife, Joan, asked me why I was willing to give up my practice and take the risk of plunging head first into the unknown. At that time, WSC was just past the idea stage, and there were no assurances of funding or success. Until faced with the question, I had not thought about my reasons for action or indeed any risk. I just knew this was the path I was supposed to take for better or for worse.

The spirit of adventure runs in my family. My grandfather was a Methodist minister who left Canada and sailed to Japan in 1910. There, he taught at Kwansei Gakuin University in Nishinomya for 40 years (Fig 1). My uncle was born, and grew up, in Japan and eventually trained as an orthopedic surgeon. He followed in my grandfather’s footsteps and traveled to China with the United Church, where he spent 13 years teaching medicine and orthopedics at the West China Union University (Fig 2).

Fig 1

Howard Wilkinson and Edna Outerbridge with colleagues and children Ralph and Dorothy at Kwansei Gakuin University, Nishinomya, Japan, circa 1915.

Fig 2

Dr Ralph E. Outerbridge with the Hseih family after a treatment at the mission hospital, Junghsien, China, 1943.

I grew up hearing their stories, immersed in their photographs, and captivated not only by their adventures, but by the magnitude of what they had done for others. I saw my predecessors as true pioneers who made sacrifices and took enormous risks to offer their services to humankind. Their stories were wrapped in an ethos of serving their fellow man, and this spirit of service was something that I became aware of at a very young age. For example, the Kwansei Gakuin motto “Mastery for Service” was hung on the wall at our home.

When Joan Haldeman asked me about my career decision, I realized that my family history was the foundation for my reason. The opportunity with WSC would fit me perfectly. I had always wanted to follow in my grandfather’s and uncle’s footsteps. And as it turned out, I was embarking on an amazing adventure with someone who possessed that same unswerving spirit of service.

Anyone who has worked with Scott Haldeman knows what sacrifices he has made and the work he has done to support the chiropractic profession, chiropractors, and those suffering from spinal disorders. When my wife, young son, and I first arrived in Botswana to set up the first clinics, it was clear to me why I was there. I was there to serve patients. And that became the focus of my work and all that WSC would come to stand for.

I believe strongly that every discussion, every decision, and every action within our profession should begin and end with the patient. When faced with a dilemma or decision, we should ask: “How will this benefit our patients?” If we keep our focus on the patient, as clinicians and as a profession, we will always do the right thing, in the right way, and for the right reason.

The focus and drive for our actions should not be on what benefits the profession. Instead, the profession will benefit when we focus on the patient. As well, the focus cannot be on financial gain or recognition. Instead, recognition comes when we focus on the patient. There is no better marketing strategy than putting the patient at the center of your care. The focus cannot be on establishing the role of chiropractic in the health care world. Instead, our role will be established and respected when we focus on the patient. If we always ask, “How is what we do benefiting the patient?” we will always do the right thing, in the right way, and for the right reason.

The Right Thing

Our profession has much to offer in health care. However, I do not think we are currently offering our “highest level of contribution.” In most countries, chiropractors see about 10% of the population.2, 3, 4, 5, 6, 7 Chiropractic patients in North America are mostly healthy, wealthy, and educated.2, 3, 4 Caring for those in need wherever they are is a lofty ideal, but we need to expand beyond the healthy, wealthy, and educated. I believe that our highest level of contribution lies where there is the most suffering and the least access to care.

Low back pain is the leading cause of disability worldwide, and it is estimated that almost a billion people worldwide are suffering from spine pain. Back and neck pain contributes more to the global burden of disease than HIV, diabetes, Alzheimer’s, malaria, stroke, lung and breast cancer combined, lower respiratory infections, and traffic-related injuries. In the United States, those with lower income and less education have 4 times higher rates of chronic pain. In low- and middle-income countries, back and neck pain have an even higher prevalence. The poor and uneducated around the world have less access to effective spine care.

Chiropractic is positioned to take the lead in spine care on a global scale. Through our work, we can contribute substantially to 1 of the largest health care issues of our time. However, if we are going to take the lead in tackling the global burden of spine pain, it is an unwavering spirit of service that will define our success and a true commitment to health care that puts our patients at the very heart of everything that we do.

The Right Way

Success of the clinician and the profession depends on the services being offered. We need to demonstrate legitimacy and competency, not by telling others how great we are, but by demonstrating our value. The best services we offer incorporate scientific evidence along with clinical expertise and responding to patient wishes and expectations—the definition of evidence-based care. For so much of what we do as chiropractors, the beauty of this is that it only involves our heads and our hands. There is no high-cost technology needed. We can have a substantial impact with very little overhead.

Wherever evidence-based care is being implemented, it seems that the reputation of chiropractors and chiropractic utilization rates are increasing. For example, in Denmark, where evidence-based, integrated, patient-centered care is the norm, there has been a steady increase in utilization. Chiropractors are integrated into the Veterans Administration and private hospitals across the United States, and the numbers are growing. In Ontario, chiropractors are integrated into hospitals and family health teams, and the Ontario Ministry of Health and Long-Term Care supports these initiatives. There are many other examples where evidence-based, integrated, people-centered spine care is being integrated into community, provincial, and national health care systems, and the same growth is occurring.

The World Health Organization has created a web platform called integratedcare4people.org. It is a resource that includes people-centered, integrated care models for countries, policy makers, and practitioners to learn from. Included are 2 examples that include chiropractic engagement, and both are successful models for the management of spinal disorders. The first is St. Michael’s Hospital in Toronto, which is recognized as a leading model. The second is World Spine Care, which is seen as a promising model and will likely be upgraded to a leading model with WSC’s more recently published research.

World Spine Care is adding spine care specialty programs to existing health care systems in Botswana (Fig 3), Ghana, Dominican Republic, and India. In each of these locations, chiropractors have equal status within the health care system as medical physicians. From our experience, evidence-based care must be a foundational principle for any government to allow spine care services to be integrated into the mainstream health care system.

Fig 3

Roisin Durcan, Geoff Outerbridge, Tim Ford, and Richard Brown, Botswana, 2015. This is the site of the first World Spine Care rural primary care clinic in Shoshong.

Building partnerships within health care systems is best for the patient and builds confidence in others that we are capable of delivering high-quality care. Partnerships create allies within the health care system that can help facilitate the sustainability and scalability of our services. Such models of care are achieving success because they are not centered on chiropractors; rather, they are centered on patients.

We are health care workers first and chiropractors second. Our identity should be tied to patient care that utilizes all of our resources, knowledge, and experience to provide the best patient care possible. If our identity is tied to a technique system, we risk losing interprofessional respect and authority. Health care systems are not looking for techniques; they are looking for comprehensive solutions to spinal disorders. These models have been successful at all levels of health care delivery, and there are many organizations to learn from.

Chiropractors alone cannot relieve the suffering of millions of people. We must shed our “scarcity mentality” and instead adopt an “abundance mentality.” There are too many people in the world that need help for us to engage in professional turf wars and animosity. Instead, we must collaborate with others who also have the training to treat spinal pain and take a leadership role in guiding other stakeholders. We need to educate, inspire, and empower communities. What we do should be about finding partners and engaging them in sustainable models of care. For example, in Botswana, we launched the WSC yoga project, where we trained local people, many with only a primary school education, to teach yoga to their communities. It has been inspiring to see the impact of the newly trained yoga teachers on their community. Not only have their classes helped to address musculoskeletal pain, but the community around the yoga classes has created a social support network and sense of empowerment for those with musculoskeletal pain.

We can already showcase examples where people-centered, integrated care is working, sustainable, and scalable, but we need more. We, as a profession, need to make these services the norm, and throughout the world, people need to associate this model with chiropractic care. We have a responsibility to bring this comprehensive model to low- and middle-income countries.

The Right Reason

If we keep our focus on the patient, we will do the right thing, the right way, and for the right reason. Compassion should be a dominant trait. A true, heartfelt, burning desire to relieve suffering is the foundation of the true spirit of service. This should be the reason for every stakeholder in spine care: clinicians, researchers, administrators, policy makers, and opinion leaders. We need to keep in mind how our decisions, research, and actions will impact the patient.

It is easy to lose sight of this goal. Recently, I was watching a volunteer associate treat a patient at 1 of the Botswana clinics. He was getting frustrated with a patient who was very expressive. She would jump each time he touched her. He was impatient because he wanted to treat her a particular way, but she did not like his approach.

I am sure we have all had this experience to some degree in practice. Compassionate care begins when we recognize that we all have our own cultural, personal, and professional biases that change over time. Our preferences and our moods may also vary from moment to moment. It is imperative, if you want to offer patient-centered care, that you reflect on and understand your own biases, moods, and preferences and do not become them. Self-monitoring should be the first step in every patient encounter. Our biases and egos may stand in the way of optimal patient care and professional focus.

As chiropractors, we often hear appreciation from our patients, and this is incredibly validating. However, on the other hand, we tend to not hear from our patients who are dissatisfied with our care. This may lead to a distorted perception that we are the greatest clinician the world has seen. Yet, in all of our work, humility is also a key element of compassion. Having a biased memory of our brilliance does not serve our patients.

I have had the privilege of working with some of the most idealistic, altruistic, and compassionate chiropractors I have ever met—chiropractors who have made sacrifices and taken risks to help those in need. The World Spine Care Clinic Supervisors spend a year running 1 of our clinics with no pay. These clinicians embody the spirit of service and sacrifice and are the heart of our organization. I want to recognize those people who have spent a year or more in this capacity for World Spine Care as leaders in our profession. These clinicians are paving the way to more opportunities for the next generation of chiropractors and setting an exemplary standard of the quality of care that chiropractors have to offer. Our profession needs more compassionate clinicians willing to make a sacrifice to step forward and join the ranks.

Moving Ahead

If our profession chooses to help those most in need and those who have no access to care, the road ahead is not an easy one. The Financing Global Health 2015 report noted that of all the global funding for improving health in low-income countries, only 1.3% was spent on noncommunicable diseases. Spending on musculoskeletal disorders including back and neck pain, which are the greatest causes of disability, is not even mentioned in the report. Faced with the leading cause of disability, no access to care and no funding available, it appears that there are some challenges ahead. But there are also solutions.

In Ottawa, Canada, there is a community health center that serves lower-income communities. Some chiropractors joined together and created a volunteer clinic where care is offered for free. It was the spirit of service from a community of chiropractors that made this happen. This solution can be implemented anywhere in the world, in any community, as long as there are chiropractors who are committed to helping those in need who cannot afford care.

World Spine Care is finding unique solutions to funding issues, including embedding the spine care centers in existing health care systems, soliciting local funding at each clinic, and engaging with existing health care institutions. World Spine Care has an excellent track record and has published papers about the model of care,15, 16 and more research is imminent. The model is constantly under review and being updated using new evidence.

The World Spine Care model is being sought after by government health care systems. They are prepared to incorporate our model and provide financial support to these programs. Organizations are starting to create salaried positions around our programs. For example, Ghana’s Health Service was the first health care system to fully fund WSC, and the Botswana Ministry of Health and Wellness has now agreed to fully fund our efforts. This is a potential solution to the spine pain crisis, and it has already begun. Any health care system at any level can incorporate the WSC model. Other chiropractic organizations or institutions could find other innovative ways to provide care for those who cannot afford it. It should be a fundamental value within our profession that we offer services to low-income communities that have no access to care.

I believe that as a profession, as national associations, and as individuals, we need to support these organizations that are bringing care to those in need and who cannot afford it, through donating either time, services, expertise, or financial donations. At WSC we envision “A world where everyone has access to the highest quality spine care possible.” I see this as an achievable goal. I have witnessed quality spine care delivery integrated into national health care systems, have watched them achieve sustainability, and can see a clear road to scalability.

I believe that if enough of us are willing to make sacrifices, or contribute to achieving this goal, it will be the unwavering spirit of service that will energize our efforts to lead the rest of the health care world in addressing this global burden. If we keep the patient at the center of all that we do, we will always do the right thing, the right way, for the right reason (Fig 4).

Fig 4

Dr Geoff Outerbridge graduated from the Canadian Memorial Chiropractic College in 2011. After owning a multidisciplinary clinic for 10 years, he joined World Spine Care (WSC) as the Clinical Director. He sold his practice in 2011 and moved to Botswana with his family for 2 years to open the pilot clinics for WSC. Now back in Canada, he lives in Chelsea, Quebec, continues to supervise the WSC clinics, and has a part-time clinical practice in Ottawa.

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): W.G.O.

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

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

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