The History of Chiropractic

At July’s Employee Rec meeting, NCMIC’s own Mike Whitmer spoke about the history of the chiropractic profession. Here’s an abbreviated version of Mike’s presentation, in case you missed it.

Q. Who is DD Palmer?

A. Daniel David (DD) Palmer is referred to as the discoverer of chiropractic. He was a magnetic healer in the late 19th century in Davenport, Iowa. At that time, there were a lot of different health care models that were vying for prominence. Of course, the medical model was one, but at that time, medical doctors had not really taken a foothold. They didn't have a robust research mechanism to prove anything that they did actually worked so they were trying things, just like the magnetic healers were trying things. The remedies people were using were potions and ointments—snake oil, essentially.

So, Palmer comes along and he had a theory of chiropractic—that the proper alignment of the spine would allow the body to function as it was made to function, and that it had the power to heal. He believed that the central nervous system runs through the spine and all functions of the body come from that central nervous system, so if the spine is out of alignment, it's going to impinge on those nerves and interfere with their performance. He thought that if we correct those misalignments and allow the central nervous system to work at its most effective, that it would cure disease. Palmer performed his first adjustment in 1895 on the janitor of his office building, Harvey Lillard who was complaining of hearing loss. Lillard hearing was restored by the adjustment.

Palmer established the Palmer School and Cure shortly after in 1897, which today is Palmer College of Chiropractic in Davenport, Iowa.

Q. What are straights and mixers and what makes them so divisive in the profession?

A. The history of the division within the profession goes back to Palmer himself, because he had this very clear philosophy of vital holistic chiropractic, where the chiropractor’s role is to identify and correct those vertebral misalignments or subluxation as they're called. When he started the Palmer School and Cure, many of the students that he was attracting had other credentials like medical or osteopathic degrees and they decided to pursue a chiropractic degree to learn more about health care. They were learning about all these different things and they brought different views on interventions to the table.

I always think that the minute DD Palmer trained the second chiropractor, there was a division within the profession because some of these new chiropractors that Palmer was training were like, “Yeah, that's great, but what about medicine? What about the extremity treatment? What about these things that are not directly related to adjusting of the spine that can benefit the patient?”

From there, this division grew and, to this day, there are two major schools of thought within chiropractic. One is that traditional Palmer model of vitalism or straight chiropractic where the chiropractor’s role is identified as identification and correction of vertebral subluxation. But these other doctors brought these other views and they became known as mixers because they were willing to mix chiropractic with other schools of thought. Today, that's known as integrative or broad scope chiropractic or mixed. Mixer is still a widely recognized term within the profession and these doctors think that chiropractic can also benefit from these other ways of treating patients.

 Taking that a step further, Palmer is training these new chiropractors that have these other thoughts. They go out across the country and establish new chiropractic colleges, and those chiropractic colleges adopt varying philosophies of chiropractic and that remains today. Now, the schools, along with most chiropractors, fall somewhere along the philosophical spectrum. But the politics of the profession kind of revolve around this historic division, which remains to this day. Today the split is not just about straight (adjustment only) vs. modalities, it’s also about the incorporation of drugs within the scope of practice.

Q. When did we start to see pushback on chiropractic from the public?

A. Going back to Palmer, when he discovered chiropractic, the medical model wasn’t really well-established either. Medical doctors were doing things that we now view as completely barbaric (like using leeches for bloodletting). It wasn’t until early in the 20th century, that the medical community really gained a foothold, primarily because they were heavily funded by the National Institutes of Health (NIH). With millions in funding, they started to experiment and build a robust research mechanism that could prove what works and what doesn't. That was so far ahead of anything that happened in chiropractic, which had no funding mechanism.

At that time, the AMA was becoming extremely powerful and throughout the 20th century, they began fighting chiropractic. They had chiropractors arrested for practicing medicine without a license. Back then, chiropractors didn't have licensure in many states, so BJ Palmer—who was DD Palmer’s son—was now running the Palmer School and he was this very charismatic, well-known leader within the chiropractic profession. He started the very first chiropractic association in order to provide a defense to chiropractors when they got arrested for practicing medicine without a license. This is something else that fuels that division because their legal defense was to draw on DD Palmer's original chiropractic philosophy and say that chiropractors can't be guilty of practicing medicine without a license because they're not practicing medicine, they're practicing chiropractic. And chiropractic is a separate and distinct profession from the practice of medicine.

 That was a legal strategy that even today, is still used as an argument for this very narrow scope, straight chiropractic philosophy—that chiropractic is separate and distinct. What does that say for integration? What does that say for working hand in hand with the medical community? This legal strategy is no longer needed because chiropractors are now licensed in all 50 states and US territories. But it is still out there feeding into this philosophical divide within the profession. So, preventing licensure, accreditation and inclusion in any federal program was the manner in which the medical establishment tried to contain and eliminate the chiropractic profession.

 The chiropractic profession responded with this legal defense and the establishment of associations to carry that defense out. But they also responded by fighting legislatively to get licensure. The first state to gain licensure was the state of Kansas in 1913. There was licensure in 40 states by 1935 and the last state to come on was Louisiana in 1974.

Q. What happened to chiropractors who weren’t licensed?

A. Many of them were arrested and jailed for practicing without a license. In mid-century America, medical doctors were at the top of the pecking order in the community and in the social order of communities all across the United States. This is the era of Marcus Welby, MD, where medical doctors were God. They were the epitome of respect and prestige in their communities and if they told a local police department, “Hey, this chiropractor is practicing medicine without a license, go shut them down”, they would do it. In fact, the last two chiropractors were only released from jail in Louisiana in 1974 after the state passed licensure. That’s still very recently, at least in my lifetime.

Q. Did licensure help resolve the rift between chiropractors and the medical community?

A. No, in fact, in the late 50s and 60s, the American Medical Association (AMA) decided to take another strategy. Because chiropractors were getting licensure, having them arrested was not going to work, so they formed a committee with the express purpose to contain and eliminate the chiropractic profession. It was called the Committee on Quackery.

The AMA was one of the most powerful lobbying and trade organizations in the world. They had publications that were the most read health care publications worldwide. One of their codes of ethics was that it was unethical for a medical doctor in good standing with the AMA to associate with an unscientific practitioner, which what they considered chiropractors to be. They said chiropractic is an unscientific cult and that they were trying to contain and eliminate it for public health and public safety. So as such, they told their members that it was unethical to associate with chiropractors.

 In a very professional sense, that meant that you're not going to, as a chiropractor, be practicing with a medical doctor because it would be unethical for the medical doctor to do so. You're not going to be able to refer, so if you have a patient and you've got them in your office and their back is exposed and you see something that looks like skin cancer, they couldn't even refer a patient to a medical doctor to have it looked at or followed up on. They would have to rely on the patient to do it.

 They couldn't refer patients for x-rays, for radiology work or basic laboratory analysis. That’s why newly graduated chiropractors, up until probably 10, 15 years ago, were told that x-ray equipment was one of the necessities they had to set up. It was ingrained in the psyche of the profession that you had to do this yourself. That’s clearly not the case now.

 Then you take it a step further. When you’re a young professional, new to town, you want to network with other professionals, but they were barred from joining the Chamber of Commerce because medical doctors were members of the Chamber of Commerce. They were barred from being members of their country clubs because medical doctors were on the boards and said they couldn’t associate with a chiropractor. The effects of this ban on “association” was really far reaching.

The AMA had other tools as well to stifle chiropractic. Beyond the code of ethics, they had a tremendously effective propaganda machine. An example, Ann Landers at that time was the most widely distributed and read syndicated columnist in the United States. She was an advice columnist and was fully owned by the AMA. They would plant letters to Ann Landers that said, “Dear Ann Landers, my husband has low back pain and is thinking about seeking the help of a chiropractor. Should we do this?” And Ann Landers would publish a response written by the AMA saying, “Absolutely not! Chiropractors are unscientific quacks and they're extremely dangerous and it's very dangerous for your husband to go to a chiropractor.” They also planted articles in Consumer Reports, another widely read publication. This was all going on through the 60s and 70s.

Q. How did the profession address this?

A. Dr. Sportelli breaks it down like this: The first battle lines in chiropractic were legislative, getting licensure so chiropractors would not be arrested for practicing medicine anymore. The next battle was litigation to sue the AMA to stop their uncompetitive activities and assault on the chiropractic profession. That was extremely difficult to do because the AMA was extremely well-funded. They were based in Chicago, Illinois, and getting an attorney to take a case against the AMA in Chicago was next to impossible. So, the chiropractic profession really worked hard to find an attorney that would take the case.

Fortunately, they found George McAndrews, who came from a chiropractic family in Clinton, Iowa. His father was a chiropractor and he remembered going out to the farms around Clinton County in the middle of the night to treat patients because the patients didn't want the chiropractor coming in broad daylight, because if word got back to their medical doctor, he/she would refuse to treat them any longer.

They also had to work to find plaintiffs that could show damages in order to have standing to sue and they were able to do that. There was one that centers around the inability to make referrals for x-rays. That was a doctor in Estes Park, Colorado, who set up a shop there and couldn't get any radiology work done and didn't have the money to invest in the radiology equipment.

Most of McAndrews’ siblings went on to become chiropractors—one of his brothers was president of Palmer College in Davenport, Jerry McAndrews, who eventually became a member of the NCMIC board. Jerry McAndrews, along with a lot of others, recruited George to take this case at a great cost to his professional career. Suing the AMA was expensive, and they didn't have good funding. The profession did a lot of fundraising around this, but George McAndrews took this on as a passion project, not as a money maker, and he self-funded a lot of the defense. The travel he had to do for fundraising and depositions he did at his own expense and sacrificed a lot to take on the case.

The first round they lost. But the judge in the case gave George McAndrews the basis for appeal. They did and the appeals court ruled in favor of the chiropractic profession The plaintiffs didn’t sue for any damages, so there was no monetary award. What they did get was an injunction requiring the AMA to publish the judge's decision in the Journal of the American Medical Association, which was the most widely read publication in health care. That was huge. They had to throw out their unethical association plank in their in their code of ethics and that has changed the profession profoundly.

Q. What’s been the impact of the Wilk v. AMA decision to date?

A. In “Contain and Eliminate” by Howard Wolinsky, a book that tells the story of Wilk v. AMA, there is an afterword with statement by several practitioners talking about what they're doing now that they would not have been able to do pre Wilk v AMA. Those are pretty compelling. There’s one by Dr. Matt Kowalski who's a board member of NCMIC and he's a hospitalist. He works for Brigham and Women's Hospital in Boston, which is a Harvard affiliated medical center. Dr. Anthony Lisi, another NCMIC board member, works at the Veterans Health Administration, and Dr. Gary Tarola’s practice was purchased by a large hospital network. Those things never would have happened, pre-1990s, so the impact it's had on the profession has really been profound.

Q. Let’s talk about current state. Where is chiropractic today?

A.  Well, the profession is in the third battle of its life—research. Before the Wilk v AMA case, there wasn’t much good chiropractic research out there at all showing the efficacy of chiropractic care. A lot of that was because of the of the AMA attacks. Most of the research in the medical community comes out of the medical schools and there wasn't a medical school around that would work with chiropractors and do any research around chiropractic benefits.

The Wilk v. AMA case kind of opened this opportunity. Dr. Sportelli, being the visionary that he is, really saw this as an opportunity where NCMIC could be the change agent that could help with this. From the early days when chiropractic research was first starting to form, NCMIC was supporting the Foundation for Chiropractic Education and Research (FCER) and that was really the only organization within the chiropractic profession that was providing funding for research. It ended up ceasing operations in the early 2000’s so NCMIC formed the NCMIC Foundation with the purpose of supporting chiropractic and alternative health care research that the NCMIC Foundation has become a primary funder of chiropractic-oriented research.

This is really where the profession is going now. It’s building a body of research that shows the efficacy and impact of chiropractic, not only on pain intervention, but on neurology and wellness and all these other things that are part of this profession, as well as cost effectiveness of conservative care. There’s a very diverse school of thought today around what chiropractic should be. The research is getting more diverse, as well. When I first started here 20 years ago, there were a handful of DC PhDs, now there's a bunch. The NCMIC Foundation has supported many of those in getting their PhDs, recognizing that if chiropractic is going advance, it’s going to have a seat at the table with policy makers, with third party payers, and have qualified people conducting quality research.

Medicare, Medicaid, Blue Cross, Blue Shield, UnitedHealth—if we're going to influence how chiropractors are paid, if we're going to influence how the public can access chiropractic care, if we want to influence chiropractors and chiropractic’s place in public health, we need PhDs at the table for those discussions. That’s one way that the NCMIC Foundation has made an impact by supporting this PhD work and developing these PhDs to serve in this role.

The NCMIC Foundation has also invested in building research mechanisms, and while we don't have the kind of money needed to really make a huge impact with just our dollars, the Foundation has been providing seed money that can be leveraged for bigger grants from the big funding sources in the research community, primarily NIH. One example is the Bakken Center at the University of Minnesota. They were able to take the seed money NCMIC had provided to get an initial grant from the NIH, which was over $14 million. That’s a huge success story for the NCMIC Foundation. It wasn't the amount of money the Foundation gave, it was how they leveraged that to prove that the project is viable and worthy of additional funding, which is what seed money is all about.