Research with impact
By Greg Kawchuk
A response to “The tail wagging the dog”
By Greg Kawchuk
As a scientist who is fortunate to speak to audiences around the world, I field questions from clinicians about a wide range of topics including chiropractic, science and research. While the questions may be about the experiments I conduct or how their results relate to practice, there is always one question that I am asked without fail. In fact, it is the same question Dr. Brad Lohrenz asks in his recent commentary in Canadian Chiropractor (“The tail wagging the dog,” October, 2019. Page 20). To paraphrase, “why don’t you researchers investigate the amazing things I see in my practice, with ‘real’ chiropractic?”
The question is an excellent one and reflects an issue that touches all health professions – the lack of sufficient scientists, time and funds to investigate everything of interest and do so with the required quality. As such, health professions must make difficult decisions about how to prioritize chronically inadequate research resources. Chiropractic is no different.
Historically, we’ve not had a good record in this regard. Like so many professions who exist at the influential end of a power spectrum, we’ve come from a past of thinking we know best (i.e. think of men historically defining women’s reproduction rights). This doctor-centric approach to developing a research agenda is highly problematic as it cannot escape being coloured by our own personal, clinical or historical interests.
Thankfully, we now realize that the best way to triage limited research resources is literally staring us in the face: our patients. While every clinician is curious about what they do, how they do it and the results they observe, these interests are secondary. What should lead the way in selecting a research agenda is a patient-centered approach that prioritizes the very people whose health challenges allow the chiropractic profession to exist in the first place.
So if we are to prioritize research of value to patients, which patient concerns are most worthy of a research investment? Any epidemiologist, economist or Las Vegas bookie would tell you the same: Focus your minimal resources where the impact will be the greatest for patients. Without a doubt, that is musculoskeletal pain and disability. Survey after survey, poll after poll and paper after paper consistently tell the same story: The overwhelming majority of people who seek chiropractic care do so for musculoskeletal pain and disability. Whether by luck or on purpose, the chiropractic profession recognized this early in its research journey and invested their hard-earned research resources into these topics. The result has been nothing short of transformational. Procedures offered most often by chiropractors that were historically spat on are now recommended in every major low back pain guideline; a colossal result that not only has a meaningful impact for the vast majority of chiropractic patients, but has increased the future security of the profession more than any other development, technique, or law. Importantly, this investment is by no means at an end. Research on pain and disability is just beginning and far from over. Now is not the time to stop this success story, but to double down.
Important questions about patient pain and disability still require answers that are currently hidden from view. Critical questions such as: “Who responds best to chiropractic?” or “How often should I see a chiropractor?” There is so much more we can achieve for both patients and our profession by continuing down this road. Still, Dr. Lorenz’s question remains.
Needing more answers
What about the results observed by chiropractors that don’t fall into the realm of pain and disability? What if there is potential for chiropractic to help others in exciting new ways but research funds have not been channelled to these areas? As mentioned before, this dilemma is as real as research resources are scarce. How will the “next” research topic be identified that will have the greatest impact for patients, or should there even be a “next” topic given limited resources?
To answer this question, I’d like to start by suggesting how not to go about answering this question. That is, to reject the traditional strategy that chiropractors use to navigate through disagreement – blame. It typically goes something like this: “My” research agenda is the right one and should be supported over others because: 1) funding has not been distributed fairly, 2) researchers have too much power, 3) science is broken (e.g. randomized control trials are flawed, population-based statistics are irrelevant, scientists do bad things etc., etc.), or 4) it’s “my” turn. All of these arguments are just that – arguments that do not really answer the question of what research is most important for patients. It’s time to move on.
There is, however, a way to answer to this question that avoids the haggard, old approach of blame (that has yet to do anything positive for chiropractic). Instead, imagine a rare opportunity to unite a diverse profession around a solution that not only works for DCs, but improves the lives for as many patients as possible.
What is the solution? Our current understanding of what patients need is ultimately a snapshot. A screen capture. A sample of the entire population. And we’ve been fortunate that these snapshots have been fairly representative whether they be about pain, disability or non-musculoskeletal conditions. But what if instead we could move beyond the snapshots, the single practitioner opinions, the small surveys or even large-scale polls? What if instead we could evaluate the needs of all chiropractic patients. Not a few. Not ten. Not ten thousand. All chiropractic patients in Canada. All. Of. Them. At once, we would have answers in our pocket that have never been available to reach down and grab. That miracle you’ve seen in practice? We’d actually know (not argue) if it is a one-off or something that happens in a large percentage of patients and worthy of further exploration. Imagine that. Moving beyond decades of argument and blame to now possess actual facts about what we do and how all patients respond.
“Act” in chiropractic
This is not a dream that might happen generations from now. This possibility is currently within our grasp. Technology exists today for chiropractors to record what happens to every patient during every visit and safely share this information in real-time with clinicians, associations, regulators, researchers, policy makers, educators and patients.
Establishing a national chiropractic health record in this way would transform the profession endlessly. If data is the new oil, imagine creating our own source of clean, ethical “oil.” A data source that would finally allow chiropractors to control their own autonomy about what they can or cannot do in practice. A tool to that would allow chiropractors to describe how safe our treatments can be and proactively identify those who might be at risk. A data source that puts the profession at the centre of developing new knowledge pertaining to prevention, prognosis, diagnosis and treatment of what concerns patients most. All for the small cost of the time and effort it takes to capture what we do on a daily basis anyway.
Although we are far behind in adopting electronic health records, the timing could not be better. Had the profession adopted electronic health records previously, the older technology of years gone by would now make it difficult to link with other databases or transfer data. As a result, we are poised on the precipice of being able to create an effective national electronic health record. Doing so would perhaps be the profession’s greatest achievement since its founding and most importantly, one that would benefit all – patients and clinicians alike. So, let us unite behind an idea that solves all the arguments about research priorities. A Canadian Chiropractic Health Record.
With that, I now have questions of my own for this audience. Will we continue to entertain arguments and waste more time blaming others about what research should or should not be funded? Will we never miss an opportunity to yet again miss another opportunity? Or, could we put aside what we as think is best for ourselves and instead do what is best for chiropractic patients. To acknowledge that while this is the best time to be a chiropractor, we need to be the best chiropractors for these times. To do something truly epic and for once, do it together. To choose to put the “act” back in chiropractic. To do something historic that will leave this profession better off than when we started for those who have yet to be chiropractors and those who will continue to seek our help.
Dr. Greg Kawchuk, DC, PhD, is a professor in the Faculty of Rehabilitation Medicine at the University of Alberta.