Journal of Manipulative and Physiological Therapeutics
Volume 32, Issue 9 , Pages 799-803, November 2009

Chiropractic Practice in the Danish Public Health Care Sector: A Reflection and Clarification of Context, Terms of Usage, and Selected Design Considerations for a Planned Qualitative Investigation

  • Corrie Myburgh, PhD

      Affiliations

    • Corresponding Author InformationSubmit requests for reprints to: Corrie Myburgh, PhD, Assistant Professor, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.

Assistant Professor, Institute of Clinical Biomechanics, University of Southern Denmark, 5230 Odense M, Denmark

Received 20 April 2009; received in revised form 18 August 2009; accepted 20 August 2009.

Article Outline

Abstract 

This commentary offers preliminary considerations around a phenomenological investigation of chiropractic services in a Danish public sector setting. In this narrative description, the main venue for chiropractic public (secondary) sector practice in the Danish context is briefly described and defined. Furthermore, a contextually relevant definition of an integral health care service is presented; and the professional importance for chiropractic in providing such services is also discussed. Finally, salient questions requiring empirical investigation in this context are posed; and selected issues around a qualitative research design approach are considered.

Key Indexing Terms: Integrative Medicine, Complementary Medicine, Alternative Medicine, Healthcare, Social Characteristics, Delivery of Health Care, Integrated, Chiropractic

 

Chiropractic has undergone unprecedented development in Denmark.1, 2, 3 Professional milestones in all 3 of its activity domains (practice, politics, and education/science) have led some to argue that, in the Danish context, the profession should no longer be viewed as a complementary and alternative (CAM) service, but rather a part of ordinary health care services.2

Notwithstanding the ongoing discourse relating to the increase of integrative health care (IHC) practices,4, 5, 6, 7 this concerted move toward wholesale inclusion differs from the fragmented attempts at sustained, government-sponsored interprofessional practice observed elsewhere in relation to chiropractic service provision.3, 6, 8, 9, 10 One milestone event in particular, the profession's unrestricted access to public (secondary) sector practice, distinguishes Danish chiropractic as an interesting case of health care professionalization.11 Specifically, at both the undergraduate and postgraduate levels, chiropractors enjoy constant contact with patients as part of governmental health care delivery, simultaneously confirming the profession's status as unique health care human resource and relevant specialist service provider.3

After more than a decade of integrated service provision, however, the broader social importance of this area of professional activity may have become apparent. Consequently, the aim of this commentary is to present the context, unique terms of usage, and a conceptual clarification around a planned phenomenological investigation of the chiropractic profession's emerging role in the Danish National Health Care Services. More specifically, public sector practice will be described and defined, the concept of integral health care service (IgLHCS) provision will be introduced, and an argument for its importance will be presented. Furthermore, pertinent research questions emerging for this unique social domain of practice will be posed; and finally, selected conceptual issues around qualitative design methods will be put forward for consideration.

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Chiropractic Service Provision in the Danish Public Sector 

The main venue for chiropractic public sector practice has been described previously.11 Since 1997, Ringe, a small town in the county of Funen, has been the location of the Ringe spinal unit that functions as a multidisciplinary outpatient back pain clinic. It services the region of Southern Denmark by accepting patient referrals from private practice and other hospital departments (approximately 3500 per year) (S O'Neill, senior chiropractic consultant, Ringe spinal unit, Denmark, personal communication, 15th of April 2009). The professional groups currently responsible for direct patient referrals include chiropractors and medical practitioners. Besides management, the unit also functions as a research and experiential training venue. The center is structured, so that patients are assessed and managed by interdisciplinary teams on a rotational basis (Fig 1). A discipline-specific senior consultant, who in turn reports to the director of the facility, heads each professional group.

In this context then, service provision is characterized by 4 key components, these being mode of funding, practice model, patient procurement strategy, and service delivery context. Thus, a contextually relevant definition for public/secondary sector practice pertaining to chiropractic services would be that of a publicly funded, interdisciplinary, specialist health care service provided in an academic context.

All public sector services are, however, through necessity constantly under governmental scrutiny.12 Therefore, notwithstanding its effect on the integration of the chiropractic profession, chiropractic's public sector practice must also be perceived as important to the needs of the society it serves to justify continued funding.13 Encouraging preliminary evidence in this regard has emerged from a health care technologies perspective.11 However, it is currently unclear whether the inclusion of chiropractic services are perceived as important, or indeed integral, by key stakeholders responsible for ongoing health care service provision in this sector.14, 15

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IgLHCS Provision—A Clarification of Terms 

Terms describing important health care services are used interchangeably in the literature.15, 16, 17 This tends to create the impression that essential, indispensable, and integral health care services are equivalent. However, this is not necessarily the case as can be gleaned from the 3 contextualized examples provided in Table 1. The latter term is of particular relevance to this discussion because it appears to describe service delivery in a more mature health care setting; is aimed at improving on existing services, rather than creating new ones; and requires a period of implementation before its effectiveness can be evaluated. In this context, then the term integral health care service is defined as follows:

A health care service that improves on the current level of service delivery to such an extent that to return to the level of service provision before its implementation would be untenable.

Table 1. A clarification of health care service delivery terms
HCS termDefinitionExample of application
IndispensableA service without which the health care delivery could not function.The provision of ambulance paramedic services16
EssentialA protocol where specific health care service requirements are identified to solve a critical health care issue.Establishing primary health care services in a particular region/country17
IntegralA service that if not delivered would render health care delivery in a particular context incomplete (suboptimal).The development of existing delivery systems for reinserting drug abusers into society.15

HCS, Health care service.

In a sense, IgLHCS delivery is an evolution of health care provision, during which necessary adaptations to the needs of contemporary society take place.18 Therefore, during the evaluation of any particular health care service as integral, the issue is not whether some form of service delivery existed before, but rather whether it would be conceivable for contemporary consumers to return to the status quo before its implementation.

To illustrate this point plainly, consider the analogy of developments in automobile technology (Fig 2A, B). One can clearly recognize the 2 pictures as crash test procedures performed on 2 small passenger vehicles. Both vehicles essentially perform the same function; however, in hindsight, the older vehicle, because of its lack of technological advancements with respect to safety features, provides a suboptimal service (by contemporary safety standards) with respect to travel safety.

For chiropractic, this interpretation has important implications. Firstly, the profession is not obliged to “prove” its services as indispensable, essential, or both, in the same manner as other established health care services. Rather, it is tasked with providing compelling evidence that, in its absence, users will be presented with an unacceptably suboptimal set of services. Furthermore, if practice integration is a process, then it can be considered a means to an end, that end being the identification of criteria (whatever they may be) useful in securing a position as integral to contemporary health care service delivery and thus relevant beyond a doubt.

A Note on IHC 

It is important that the reader distinguishes IgLHCS from IHC. Also sometimes referred to as integrative/integrated medicine,7 IHC broadly refers to a specific type of team-oriented health care practice, where a degree of the integration between conventional and CAM can be observed.6, 19 Integral health care service makes no specific reference to CAM; however, it is quite feasible that one might observe a case where a specific case of IHC could over time also prove to be an IgLHCS.

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Capturing the Emergence of Chiropractic in This Context 

Access to government-sponsored health care delivery has undoubtedly benefited the Danish chiropractic community's status and legitimacy. However, as has been demonstrated previously, the trade-off is a lowering in professional autonomy and control as the profession is exposed to the influence of powerful third parties.3 Thus, while chiropractors may be contributing meaningfully to the emergence of an integral musculoskeletal health care service, this dynamic process may also be affecting the nature of the profession itself. Therefore, interesting issues residing at the level of paradigms (philosophy), models of practice (professional identity), and service delivery (patient management) outcomes may be emerging. For instance, at the level of paradigms, 2 important question spring to mind:

1.Given the reclassification argument of chiropractic services as part of ordinary health care, is the notion of IHC, which by definition requires at least one CAM profession,4 still relevant?

2.Against the backdrop of a self-critical conceptual model of world medicine,7, 20 is it likely that we are witnessing a case of broadening of the biomedical paradigm or a co-option of specific CAM therapies without its associated philosophical tenets?

At the level of professional practice models, it is important to clarify where this model of practice lies on the team practice model continuum of Boon et al,4 on what basis the model was developed, and whether feasible alternatives should be considered in this context of services delivery.

Finally, at the level of health care delivery outcomes, what evidence supports the view that the chiropractic profession contributes to a unique service delivered to the local community, without which health care in this sector would be considered suboptimal?

Initial Perspectives for a Qualitative Research Approach 

The questions above, which question a rather complicated social action in its natural setting, fall squarely within the definition of qualitative research and under “the multidisciplinary care issues” theme previously identified as relevant to chiropractic.21, 22

A key challenge in successfully reflecting this phenomenon will be to identify and access relevant role players. More specifically, this particular case (chiropractic practice in the Danish public sector) is not directly observable and therefore requires proxy units of observation.3, 21 Moreover, factors relevant to IgLHCS status are likely to be embedded in and dispersed across a variety of individuals functioning within this social domain as illustrated in Figure 3. However, at this point, it is highly probable that relevant data sources lie undiscovered; and therefore, this initial view of a representative sample is likely to be an underrepresentation. The challenge, therefore, will be to create a sampling framework, one that cannot be predetermined, so that the relevant insider perspectives might eventually be captured. In this, the empirical investigation will be reliant on the insights of an appropriate gatekeeper; and therefore, its success hinges strongly on the identification of this individual to guide the initial sampling process.

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Conclusion 

A self-critical conceptual model for an integrated world medicine with an equal partnership for CAM professions is still currently a naive ideal. Nevertheless, chiropractors in the Danish public sector setting do appear to be practicing on equal footing with established health care professions. Thus, in this milieu, a rare opportunity exists to consider milestones in the chiropractic professional project that may lie beyond integration.

The salient points from this narrative can be summarized as follows:

•Public sector practice is a publicly funded, interdisciplinary, specialist health care service provided in an academic milieu.

•An IgLHCS is a health care service that, after a period of development, is considered key to the optimal function of health care in a particular context.

•To be considered part of IgLHCS provision is important for the chiropractic profession because it may present a more advanced form of health care integration.

•Emergent questions relating to practice in this domain are likely to affect chiropractic at the level of philosophy, professional identity, and clinical management.

•Empirical investigation of these phenomena would be well suited to qualitative methods and would contribute to the theme of multidisciplinary care issues previously identified.

It is possible that service integration in itself may represent only the start of a process, one that culminates in the development of integral health care provider status, a claim that provides both unquestioned professional legitimacy but, more importantly, unquestioned benefit to contemporary society. However, the nature of the profession involved in this process is likely to be fundamentally affected at the level of philosophy, professional practice, and patient management in interesting and unpredictable ways.

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Funding Sources and Potential Conflicts of Interest 

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

Practical Applications


•Public sector practice in the Danish context is defined by its mode of patient procurement, funding mechanism, and educational interests.

•Integral health care service is an appropriate and operationalizable term from which to gauge the role of chiropractic service in the public sector.

•Questions relevant to current debates at the level of paradigms, professional practice models, and health care delivery outcomes are identifiable in this context, thus requiring clear conceptualization to investigate this complex unit of analysis (chiropractic).

•At least 6 stakeholder groups contain relevant units of observation and require consideration as an appropriate sampling framework is developed.

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References 

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PII: S0161-4754(09)00275-9

doi:10.1016/j.jmpt.2009.10.011

Refers to erratum:

  • Errata

    Journal of Manipulative and Physiological Therapeutics February 2010 (Vol. 33, Issue 2, Page 164)

Journal of Manipulative and Physiological Therapeutics
Volume 32, Issue 9 , Pages 799-803, November 2009

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