In Response: To Keating

We endorse Dr Keating's support of our proposed model.1.Flanagan J Giordano J The role of the institution in developing the next generation chiropractor: clinician and researcher.J Manipulative Physiol Ther. 2002; 25: 193-195Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In concurrence, major impediments to developing chiropractic clinician-researchers are (1) mistaking dogma for philosophy and (2) an economic infrastructure that sacrifices academic excellence for financial gain. Comment is warranted on both issues. If chiropractic seeks equity in a pluralistic biomedical society, it is important to achieve philosophical congruence within that culture. Throughout biomedicine, this philosophical orientation is that of science, a dynamic worldview that recognizes and serves a changing epistemology. Dogma is the antithesis of this process. By creating untestable assumptions and solidifying belief without evidence, dogma limits critical thinking and ultimately, free will.2.Keating JC Commentary: the specter of dogma.J Can Chiropr Assoc. 2001; 45: 76-80Google Scholar This is not only inconsistent with the modern philosophy of science3.Fetzer JH Philosophy of science. Paragon House, New York1993Google Scholar but may also threaten ethical precepts integral to much of medicine. Within the Principlist orientation, a primary ethical imperative is veracity,4.Beauchamp TL Childress JF Principles of biomedical ethics.5th ed. Oxford, New York2001Google Scholar achieved within the culture (through ongoing theoretical revision and acquiring new knowledge) and embodied by individuals (through critical thinking, skepticism, and obligation to communicate viable truth in clinical contexts).5.Mechanic D Changing medical organization and the erosion of trust.Milbank Q. 1996; 74: 171-189Crossref PubMed Scopus (364) Google Scholar A recent report6.Sikorski DM Grod JP The unsubstantiated web site claims of chiropractic colleges in Canada and the United States.J Chiropr Educ. 2003; 17: 113-119Google Scholar revealed lack of truthfulness underlying unsubstantiated claims propagated by several chiropractic colleges. Truthfulness is essential to fidelity and fundamental to the clinician-patient relationship. It is also a core scientific value and the basis for inquiry. Should this not be a primary tenet promulgated by academia? Given that ethics of a profession are represented and subserved by its institutions of education, what message is communicated by such (dogmatic) nonveracity to students, as well as scholars in the medical community as a whole? The scholarly environment trains students to seek truth through broadly accepted methods that may expand the field by developing new avenues of investigation. Without these skills, students lack the discipline to be critical, be self-changing, and appreciate the dynamics of scientific knowledge and philosophy. Dogmatism fosters antiprofessionalism and may threaten the ability of future generations of chiropractors to become effective citizens in a pluralistic biomedical society. The lack of an academic model that embraces a scholarly climate can purloin both chiropractic educational institutions (eg, schools) and the culture of chiropractic as a whole. The scholarly model that we have advocated is the cornerstone of academic medicine and higher education. Therein, philosophy is both a process and a tool that allows for intellectual evaluation based upon an expanding body of knowledge.7.Pap A An introduction to the philosophy of science. Free Press of Glencoe, New York1962Google Scholar How that knowledge is achieved and/or regarded is reliant upon the culture in which it exists.8.Berger P Kuckman T The social construction of reality. Routledge and Keegan Paul, London1967Google Scholar If chiropractic strives to remain viable in the postmodern medical community, it must embrace scientific philosophy as a foundation upon which to validate its role in providing health-focused patient care. The Association of Chiropractic Colleges paradigm has devised a structural framework for the integration of chiropractic to the public health community.9.Association of Chiropractic CollegesThe ACC chiropractic paradigm.J Manipulative Physiol Ther. 1996; 19: 634-637Google Scholar Focal to this is an evidence house, in which philosophy is the foundation built upon relationships with other health care providers. Arising from this foundation is a conceptual edifice of experience and knowledge that affects patient health. This integration with other health care providers demands a scientific philosophical approach and appreciation of biopsychosocial models. This affords and allows the development of research-based education and the enhancement of professional stature and public perception. If chiropractic colleges are to increase their attractiveness for competitive research subsidy (thereby diminishing reliance upon tuition-driven economics), 2 things must occur. First is the adoption and adherence to scientific philosophy as a cornerstone of theoretical and practical chiropractic education. Second is a revision of culture based upon this philosophical approach. Students must be enfranchised to the philosophy of science and recognize the necessity to embody that philosophical approach across multiple domains of their professional lives. Medical professionals must often confront circumstances that test philosophical and ethical integrity.10.Connelly JE DalleMura S Ethical problems in the medical office.JAMA. 1988; 260: 812-815Crossref PubMed Scopus (34) Google Scholar These range from requisite critical thinking11.Flanagan J Huff GL Editorial: the institutions' role in training chiropractors to analyze literature effectively.J Chiropr Educ. 2003; 17: vGoogle Scholar to the stringency of the fiduciary environment of practice.12.Dworkin G Paternalism.Monist. 1972; 56: 64-84Crossref Google Scholar Revision, across domains of chiropractic culture, may be important to solidifying the philosophical foundation through which true cooperativity within the biomedical community could occur. Within a pluralistic medical society, the role and scope of each discipline should be justifiable, evidence-based, and consistent with the philosophical orientation of the entire community. Failure to achieve this will undermine attempts at integration and establish conflicting separatism in the future. Integration into a broader (medical) society can only be achieved if chiropractic is integrated within itself. The schism in chiropractic culture is a persistently problematic issue.13.Coulter I Chiropractic: a philosophy for alternative health care. Butterworth-Heinemann, Woburn, MA1999Google Scholar This divergence is not one of philosophy, but of dogma. The incorporation of the scientific philosophical orientation throughout chiropractic culture may provide evidentiary means to bridge that schism. The elegance of this approach is that it allows for effective communication according to a conceptual framework that is built upon and committed to validity, veracity, and openness to change. The institution must play a role in facilitating the changes to achieve professional success. The “institution” consists not only of colleges, but also the culture and climate in which they exist. In practicality, how might such ends be achieved? They require an institutional environment that emphasizes and explicitly advances scholarship.14.Giordano J Stapleton S Boatwright D Huff G Blending the boundaries: steps toward the integration of complementary and alternative practice to mainstream medicine.J Altern Complement Med. 2002; 8: 897-906Crossref PubMed Scopus (60) Google Scholar, 15.Giordano J Garcia MK Boatwright D Klein K Complementary and alternative medicine in mainstream public health: a role for research in fostering integration.J Altern Complement Med. 2003; 9: 1-5Crossref PubMed Scopus (36) Google Scholar This includes raising standards for admission (increasing scientific enfranchisement of students and requiring a higher level of intellectual maturity), expanding (pregraduate and postgraduate) curricula to emphasize critical thinking, research/scientific methodology, vesting students to continued learning, and developing cooperative programs for educational exchange. If integrative progress is to occur, it is important to develop and promote a professional environment that is committed to scientific philosophy, dedicated to evidence-based knowledge, open to epistemic revision, and obligated to ethical patient-centered care. The Role of the Institution in Developing the Next-Generation Chiropractor: Clinician and ResearcherJournal of Manipulative & Physiological TherapeuticsVol. 28Issue 1PreviewFlanagan and Giordano1 have offered a useful model of institutional function (their Figure 1) which illustrates the role that research (and more generally, scholarship) can and ought to play within schools of chiropractic. As well, they have touched upon 2 (perhaps the most important) factors which have inhibited the development of research climates within our institutions: “philosophy” and poverty. A word about each seems in order. Full-Text PDF

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