Secondary Legitimacy: A Key Mainstream Health Care Inclusion Strategy for the Danish Chiropractic Profession?

Chiropractic has matured into a legitimate health care profession in many parts of the world. However, its “outsider” classification of complementary and alternative (CAM) and a relative lack of penetration into ordinary health care services (OHCS) frustrate its efforts of cementing a position among those functioning in the highly contested musculoskeletal health care arena.1Hafferty FW Light DW Professional dynamics and the changing nature of medical work.J Health Soc Behav. 1995; : 132-153Crossref PubMed Google Scholar This tension and consequent moves toward mainstream inclusion have been observed with interest by contemporary social scientists as chiropractic’s professional project is considered a test case, likely to affect other CAM professions with similar aspirations.2Kelner M Wellman B Boon H Welsh S Responses of established healthcare to the professionalization of complementary and alternative medicine in Ontario.Soc Sci Med. 2004; 59: 915-930Crossref PubMed Scopus (68) Google Scholar, 3Kelner M Wellman B Welsh S Boon H How far can complementary and alternative medicine go? The case of chiropractic and homeopathy.Soc Sci Med. 2006; 63: 2617-2627Crossref PubMed Scopus (46) Google Scholar In this regard, emergent theoretical frameworks such as “boundary work” and “countervailing powers” maintain that professions acting in contested niche areas cannot rely on primary legitimacy based on professional trait characteristics or legislated position (social closure) alone. Rather, the profession must develop more subtle secondary legitimization strategies in order to sustain its position.It is against this backdrop and observations suggesting that chiropractic's professional project may have stalled to a certain degree,4Villanueva-Russell Y Evidence-based medicine and its implications for the profession of chiropractic.Soc Sci Med. 2005; 60: 545-561Crossref PubMed Scopus (58) Google Scholar, 5Meeker WC Haldeman S Chiropractic: a profession at the crossroads of mainstream and alternative medicine.Ann Intern Med. 2002; 136: 216-227Crossref PubMed Scopus (219) Google Scholar, 6Myburgh C Mouton J Developmental issues in chiropractic: a South African practitioner and patient perspective.J Manipulative Physiol Ther. 2007; 30: 206-214Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 7Greene BR Smith M Allareddy V Haas M Referral patterns and attitudes of primary care physicians towards chiropractors.BMC Complement Altern Med. 2006; 6: 5Crossref PubMed Scopus (43) Google Scholar that we submit the view that secondary legitimacy in the chiropractic context deserves elucidation. In this essay, we present a brief synopsis of secondary legitimacy followed by a contextualized example (Danish chiropractic) where the profession appears to have reached significant milestones in this regard.Secondary Legitimacy and ChiropracticA secondary legitimating strategy can be broadly defined as a factor (process), which enhances (as opposed to establishes) legitimacy, resulting in improved professional status. Although legitimating strategies typically originate from activity in 1 of the 3 professional domains, i.e., its discipline (teaching and science), politics and practice, they tend to straddle more than 1, thus exerting influence in multiple domains (Fig 1). This multidomain influence results in an enhanced legitimacy pool potentially available to individuals acting in any of the domains, thus allowing the profession to protect and enhance its status effectively. Important examples of secondary legitimization in health care include disciplinary endorsement, peer association legitimacy, and third party (stakeholder) influences.2Kelner M Wellman B Boon H Welsh S Responses of established healthcare to the professionalization of complementary and alternative medicine in Ontario.Soc Sci Med. 2004; 59: 915-930Crossref PubMed Scopus (68) Google Scholar, 4Villanueva-Russell Y Evidence-based medicine and its implications for the profession of chiropractic.Soc Sci Med. 2005; 60: 545-561Crossref PubMed Scopus (58) Google ScholarDisciplinary EndorsementThis legitimating strategy negates claims of nonscientific practices from other established professions and can even lay claim to a niche area through a superior disciplinary reputation. This is strongly linked to the profession's ongoing contribution to science. Disciplinary endorsement should be distinguished from general disciplinary activity (a primary legitimating strategy), the function of which is to demonstrate adequate training of candidates to a certain level for legal purposes, this level usually being determined and regulated by government.Peer AssociationPeer association contributes to professional legitimacy by indicating to society, the inclusion of a professional amongst the recognized inter-professional activity (relationships) supporting health care practices.Third Party (Stakeholder) InfluencesThird party organizations are entities that can boost the image of a profession through association. This party acts entirely in self interest and the secondary legitimacy gained is accidental and dependent on ongoing shared benefit.A Contextualized ExampleAt the close of the 1970s, the Danish chiropractic profession was established as a legitimate health care profession, however, functioning in the informal sector of musculoskeletal health care. Practice legislation with a low level of reimbursement had been achieved; practices were thriving, and those wanting to study chiropractic could do so at a number of colleges in North America or the United Kingdom. Today, however, the 527 practitioner strong profession (http://www.kiropraktor-foreningen.dk/index2.php) is considered well integrated in the Danish primary health care system8Hartvigsen J Sorensen LP Graesborg K Grunnet-Nilsson N Chiropractic patients in Denmark: a short description of basic characteristics.J Manipulative Physiol Ther. 2002; 25: 162-167Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar and appears to be rapidly approaching the position of OHCS provider.In the context of the theoretical framework presented, 2 questions spring to mind:1.How did the profession find itself in a position to develop its secondary legitimacy? and2.Is there any indication of secondary legitimization?We the to the being to the that the Danish chiropractic itself in a from which could mainstream from of the were in such a practice, and Chiropractic Danish Chiropractic into a are and a of the profession's example of this is the for Chiropractic and by the profession and the Danish health this in the of and include and the of the professional shared of is in the they to those with and Danish to a chiropractic of The is of and typically to sustain the for Chiropractic and as well as wanting to a to on an than for have had to sustain through Danish a efforts in a the profession gained to the and of the Danish However, a was in this the profession was in a health with a medical more is into in Danish the to a of issues and professional milestones reached and we have examples from of the 3 professional domains 1). is view that the of of issues is considered a professional its legitimacy and However, in the context of is more to is that the of to the profession toward mainstream health and to have in domains, affect more than in to secondary legitimization strategies appears in 2 or more of in to the in this the of legitimacy and that secondary legitimization strategies have been with a of professional and legislation the patient to which be This the at a as well as a reimbursement on chiropractic number of This was by health care practitioner are in and care is and Chiropractic was to the patients to were to the are in a position to secondary sector are by the to be a of its health care discipline and and in an alternative to medicine and this the for medical and chiropractic as a mainstream profession, on with the health care politics and a position at the of the that the of chiropractic and of medical and chiropractic at this level to develop and thus the health care the and a for in health for training be training in the the and in sector the health care and to patients politics and with its to the health care the profession to be to its niche areas of with chiropractic in in areas the of chiropractic practice, and and professional of to into niche areas by other as for and The of a of training such and by the profession itself and the health care is the professional to on in as well as practices through discipline and in a to professional and a into mainstream health legitimacy party sector for and of medical and chiropractic training in the secondary in in a many of the are and a to in the such as and professional of in primary and secondary and and to a profession that is in the of of OHCS for its there is indication that was by a position of relative through as well as professional is a with a be to professional as a where can be for medicine in and Health 25: PubMed Scopus Google Scholar in is a highly and chiropractic a number of examples suggesting the The and Chiropractic with to are integrated with mainstream health care and to be a profession J Sorensen LP Graesborg K Grunnet-Nilsson N Chiropractic patients in Denmark: a short description of basic characteristics.J Manipulative Physiol Ther. 2002; 25: 162-167Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar the other chiropractic functioning in such as the United and to be in a similar to the Danish This however, of the of this and to we maintain that Danish chiropractic's is at in to the of secondary legitimization strategies and is a likely for its strong toward mainstream profession's legitimacy is established in domains, that its and professions a level of legitimacy to with established health strategies are that can boost legitimacy to the level of health care Danish chiropractic has of and its professional to that of an to musculoskeletal health is the example of the chiropractic profession being into mainstream health care as an Chiropractic has matured into a legitimate health care profession in many parts of the world. However, its “outsider” classification of complementary and alternative (CAM) and a relative lack of penetration into ordinary health care services (OHCS) frustrate its efforts of cementing a position among those functioning in the highly contested musculoskeletal health care arena.1Hafferty FW Light DW Professional dynamics and the changing nature of medical work.J Health Soc Behav. 1995; : 132-153Crossref PubMed Google Scholar This tension and consequent moves toward mainstream inclusion have been observed with interest by contemporary social scientists as chiropractic’s professional project is considered a test case, likely to affect other CAM professions with similar aspirations.2Kelner M Wellman B Boon H Welsh S Responses of established healthcare to the professionalization of complementary and alternative medicine in Ontario.Soc Sci Med. 2004; 59: 915-930Crossref PubMed Scopus (68) Google Scholar, 3Kelner M Wellman B Welsh S Boon H How far can complementary and alternative medicine go? The case of chiropractic and homeopathy.Soc Sci Med. 2006; 63: 2617-2627Crossref PubMed Scopus (46) Google Scholar In this regard, emergent theoretical frameworks such as “boundary work” and “countervailing powers” maintain that professions acting in contested niche areas cannot rely on primary legitimacy based on professional trait characteristics or legislated position (social closure) alone. Rather, the profession must develop more subtle secondary legitimization strategies in order to sustain its is against this backdrop and observations suggesting that chiropractic's professional project may have stalled to a certain degree,4Villanueva-Russell Y Evidence-based medicine and its implications for the profession of chiropractic.Soc Sci Med. 2005; 60: 545-561Crossref PubMed Scopus (58) Google Scholar, 5Meeker WC Haldeman S Chiropractic: a profession at the crossroads of mainstream and alternative medicine.Ann Intern Med. 2002; 136: 216-227Crossref PubMed Scopus (219) Google Scholar, 6Myburgh C Mouton J Developmental issues in chiropractic: a South African practitioner and patient perspective.J Manipulative Physiol Ther. 2007; 30: 206-214Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 7Greene BR Smith M Allareddy V Haas M Referral patterns and attitudes of primary care physicians towards chiropractors.BMC Complement Altern Med. 2006; 6: 5Crossref PubMed Scopus (43) Google Scholar that we submit the view that secondary legitimacy in the chiropractic context deserves elucidation. In this essay, we present a brief synopsis of secondary legitimacy followed by a contextualized example (Danish chiropractic) where the profession appears to have reached significant milestones in this Legitimacy and ChiropracticA secondary legitimating strategy can be broadly defined as a factor (process), which enhances (as opposed to establishes) legitimacy, resulting in improved professional status. Although legitimating strategies typically originate from activity in 1 of the 3 professional domains, i.e., its discipline (teaching and science), politics and practice, they tend to straddle more than 1, thus exerting influence in multiple domains (Fig 1). This multidomain influence results in an enhanced legitimacy pool potentially available to individuals acting in any of the domains, thus allowing the profession to protect and enhance its status effectively. Important examples of secondary legitimization in health care include disciplinary endorsement, peer association legitimacy, and third party (stakeholder) influences.2Kelner M Wellman B Boon H Welsh S Responses of established healthcare to the professionalization of complementary and alternative medicine in Ontario.Soc Sci Med. 2004; 59: 915-930Crossref PubMed Scopus (68) Google Scholar, 4Villanueva-Russell Y Evidence-based medicine and its implications for the profession of chiropractic.Soc Sci Med. 2005; 60: 545-561Crossref PubMed Scopus (58) Google ScholarDisciplinary EndorsementThis legitimating strategy negates claims of nonscientific practices from other established professions and can even lay claim to a niche area through a superior disciplinary reputation. This is strongly linked to the profession's ongoing contribution to science. Disciplinary endorsement should be distinguished from general disciplinary activity (a primary legitimating strategy), the function of which is to demonstrate adequate training of candidates to a certain level for legal purposes, this level usually being determined and regulated by government.Peer AssociationPeer association contributes to professional legitimacy by indicating to society, the inclusion of a professional amongst the recognized inter-professional activity (relationships) supporting health care practices.Third Party (Stakeholder) InfluencesThird party organizations are entities that can boost the image of a profession through association. This party acts entirely in self interest and the secondary legitimacy gained is accidental and dependent on ongoing shared secondary legitimating strategy can be broadly defined as a factor (process), which enhances (as opposed to establishes) legitimacy, resulting in improved professional status. Although legitimating strategies typically originate from activity in 1 of the 3 professional domains, i.e., its discipline (teaching and science), politics and practice, they tend to straddle more than 1, thus exerting influence in multiple domains (Fig 1). This multidomain influence results in an enhanced legitimacy pool potentially available to individuals acting in any of the domains, thus allowing the profession to protect and enhance its status effectively. Important examples of secondary legitimization in health care include disciplinary endorsement, peer association legitimacy, and third party (stakeholder) influences.2Kelner M Wellman B Boon H Welsh S Responses of established healthcare to the professionalization of complementary and alternative medicine in Ontario.Soc Sci Med. 2004; 59: 915-930Crossref PubMed Scopus (68) Google Scholar, 4Villanueva-Russell Y Evidence-based medicine and its implications for the profession of chiropractic.Soc Sci Med. 2005; 60: 545-561Crossref PubMed Scopus (58) Google Scholar Disciplinary EndorsementThis legitimating strategy negates claims of nonscientific practices from other established professions and can even lay claim to a niche area through a superior disciplinary reputation. This is strongly linked to the profession's ongoing contribution to science. Disciplinary endorsement should be distinguished from general disciplinary activity (a primary legitimating strategy), the function of which is to demonstrate adequate training of candidates to a certain level for legal purposes, this level usually being determined and regulated by This legitimating strategy negates claims of nonscientific practices from other established professions and can even lay claim to a niche area through a superior disciplinary reputation. This is strongly linked to the profession's ongoing contribution to science. Disciplinary endorsement should be distinguished from general disciplinary activity (a primary legitimating strategy), the function of which is to demonstrate adequate training of candidates to a certain level for legal purposes, this level usually being determined and regulated by AssociationPeer association contributes to professional legitimacy by indicating to society, the inclusion of a professional amongst the recognized inter-professional activity (relationships) supporting health care association contributes to professional legitimacy by indicating to society, the inclusion of a professional amongst the recognized inter-professional activity (relationships) supporting health care Party (Stakeholder) InfluencesThird party organizations are entities that can boost the image of a profession through association. This party acts entirely in self interest and the secondary legitimacy gained is accidental and dependent on ongoing shared party organizations are entities that can boost the image of a profession through association. This party acts entirely in self interest and the secondary legitimacy gained is accidental and dependent on ongoing shared Contextualized ExampleAt the close of the 1970s, the Danish chiropractic profession was established as a legitimate health care profession, however, functioning in the informal sector of musculoskeletal health care. Practice legislation with a low level of reimbursement had been achieved; practices were thriving, and those wanting to study chiropractic could do so at a number of colleges in North America or the United Kingdom. Today, however, the 527 practitioner strong profession (http://www.kiropraktor-foreningen.dk/index2.php) is considered well integrated in the Danish primary health care system8Hartvigsen J Sorensen LP Graesborg K Grunnet-Nilsson N Chiropractic patients in Denmark: a short description of basic characteristics.J Manipulative Physiol Ther. 2002; 25: 162-167Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar and appears to be rapidly approaching the position of OHCS provider.In the context of the theoretical framework presented, 2 questions spring to mind:1.How did the profession find itself in a position to develop its secondary legitimacy? and2.Is there any indication of secondary legitimization?We the to the being to the that the Danish chiropractic itself in a from which could mainstream from of the were in such a practice, and Chiropractic Danish Chiropractic into a are and a of the profession's example of this is the for Chiropractic and by the profession and the Danish health this in the of and include and the of the professional shared of is in the they to those with and Danish to a chiropractic of The is of and typically to sustain the for Chiropractic and as well as wanting to a to on an than for have had to sustain through Danish a efforts in a the profession gained to the and of the Danish However, a was in this the profession was in a health with a medical more is into in Danish the to a of issues and professional milestones reached and we have examples from of the 3 professional domains 1). is view that the of of issues is considered a professional its legitimacy and However, in the context of is more to is that the of to the profession toward mainstream health and to have in domains, affect more than in to secondary legitimization strategies appears in 2 or more of in to the in this the of legitimacy and that secondary legitimization strategies have been with a of professional and legislation the patient to which be This the at a as well as a reimbursement on chiropractic number of This was by health care practitioner are in and care is and Chiropractic was to the patients to were to the are in a position to secondary sector are by the to be a of its health care discipline and and in an alternative to medicine and this the for medical and chiropractic as a mainstream profession, on with the health care politics and a position at the of the that the of chiropractic and of medical and chiropractic at this level to develop and thus the health care the and a for in health for training be training in the the and in sector the health care and to patients politics and with its to the health care the profession to be to its niche areas of with chiropractic in in areas the of chiropractic practice, and and professional of to into niche areas by other as for and The of a of training such and by the profession itself and the health care is the professional to on in as well as practices through discipline and in a to professional and a into mainstream health legitimacy party sector for and of medical and chiropractic training in the secondary in in a the close of the 1970s, the Danish chiropractic profession was established as a legitimate health care profession, however, functioning in the informal sector of musculoskeletal health care. Practice legislation with a low level of reimbursement had been achieved; practices were thriving, and those wanting to study chiropractic could do so at a number of colleges in North America or the United Kingdom. Today, however, the 527 practitioner strong profession (http://www.kiropraktor-foreningen.dk/index2.php) is considered well integrated in the Danish primary health care system8Hartvigsen J Sorensen LP Graesborg K Grunnet-Nilsson N Chiropractic patients in Denmark: a short description of basic characteristics.J Manipulative Physiol Ther. 2002; 25: 162-167Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar and appears to be rapidly approaching the position of OHCS In the context of the theoretical framework presented, 2 questions spring to mind:1.How did the profession find itself in a position to develop its secondary legitimacy? and2.Is there any indication of secondary the to the being to the that the Danish chiropractic itself in a from which could mainstream from of the were in such a practice, and Chiropractic Danish Chiropractic into a are and a of the profession's example of this is the for Chiropractic and by the profession and the Danish health this in the of and include and the of the professional The Danish Chiropractic into a are and a of the profession's example of this is the for Chiropractic and by the profession and the Danish health this in the of and include and the of the professional shared of is in the they to those with and Danish to a chiropractic of The is of and typically to sustain the for Chiropractic and as well as wanting to a The shared of is in the they to those with and Danish to a chiropractic of The is of and typically to sustain the for Chiropractic and as well as wanting to a to on an than for have had to sustain through Danish a efforts in a the profession gained to the and of the Danish However, a was in this the profession was in a health with a medical more is into in Danish the to a of issues and professional milestones reached and we have examples from of the 3 professional domains 1). is view that the of of issues is considered a professional its legitimacy and However, in the context of is more to is that the of to the profession toward mainstream health and to have in domains, affect more than in to secondary legitimization strategies appears in 2 or more of in to the in this the of legitimacy and that secondary legitimization strategies have been with a of professional and legislation the patient to which be This the at a as well as a reimbursement on chiropractic number of This was by health care practitioner are in and care is and Chiropractic was to the patients to were to the are in a position to secondary sector are by the to be a of its health care discipline and and in an alternative to medicine and this the for medical and chiropractic as a mainstream profession, on with the health care politics and a position at the of the that the of chiropractic and of medical and chiropractic at this level to develop and thus the health care the and a for in health for training be training in the the and in sector the health care and to patients politics and with its to the health care the profession to be to its niche areas of with chiropractic in in areas the of chiropractic practice, and and professional of to into niche areas by other as for and The of a of training such and by the profession itself and the health care is the professional to on in as well as practices through discipline and in a to professional and a into mainstream health legitimacy party sector for and of medical and chiropractic training in the secondary in in a to on an than for have had to sustain through Danish a efforts in a the profession gained to the and of the Danish However, a was in this the profession was in a health with a medical more is into in Danish the to a of issues and professional milestones reached and we have examples from of the 3 professional domains 1). is view that the of of issues is considered a professional its legitimacy and However, in the context of is more to is that the of to the profession toward mainstream health and to have in domains, affect more than in to secondary legitimization strategies appears in 2 or more of in to the in this the of legitimacy and that secondary legitimization strategies have been with a of many of the are and a to in the such as and professional of in primary and secondary and and to a profession that is in the of of OHCS for its there is indication that was by a position of relative through as well as professional is a with a be to professional as a where can be for medicine in and Health 25: PubMed Scopus Google Scholar in is a highly and chiropractic a number of examples suggesting the The and Chiropractic with to are integrated with mainstream health care and to be a profession J Sorensen LP Graesborg K Grunnet-Nilsson N Chiropractic patients in Denmark: a short description of basic characteristics.J Manipulative Physiol Ther. 2002; 25: 162-167Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar the other chiropractic functioning in such as the United and to be in a similar to the Danish This however, of the of this and to Although many of the are and a to in the such as and professional of in primary and secondary and and to a profession that is in the of of OHCS for its there is indication that was by a position of relative through as well as professional reputation. is a with a be to professional as a where can be for medicine in and Health 25: PubMed Scopus Google Scholar in is a highly and chiropractic a number of examples suggesting the The and Chiropractic with to are integrated with mainstream health care and to be a profession J Sorensen LP Graesborg K Grunnet-Nilsson N Chiropractic patients in Denmark: a short description of basic characteristics.J Manipulative Physiol Ther. 2002; 25: 162-167Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar the other chiropractic functioning in such as the United and to be in a similar to the Danish This however, of the of this and to we maintain that Danish chiropractic's is at in to the of secondary legitimization strategies and is a likely for its strong toward mainstream profession's legitimacy is established in domains, that its and professions a level of legitimacy to with established health strategies are that can boost legitimacy to the level of health care Danish chiropractic has of and its professional to that of an to musculoskeletal health is the example of the chiropractic profession being into mainstream health care as an In we maintain that Danish chiropractic's is at in to the of secondary legitimization strategies and is a likely for its strong toward mainstream profession's legitimacy is established in domains, that its and professions a level of legitimacy to with established health strategies are that can boost legitimacy to the level of health care Danish chiropractic has of and its professional to that of an to musculoskeletal health is the example of the chiropractic profession being into mainstream health care as an

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