The research crisis in American institutions of complementary and integrative health: one proposed solution for chiropractic profession

In their 2018 article, Adams et al. [1] drew attention to a crisis in what they termed a sustainable research culture in chiropractic. They state “At present however, there is not a mature research culture across the chiropractic profession largely due to deficiencies in research capacity and leadership, which may be caused by a lack of chiropractic teaching programs in major universities.” ([1], p1) In response they created the Chiropractic Academy for Research Leadership (CARL) whose purpose is to provide mentorship of successful early-career chiropractic researchers. This is an excellent program and deserves to be successful.

However, in the US, the problem is less of a lack of trained researchers than a lack of research infrastructure. Through their K awards, National Institute of Health (NIH) offers research training grants to individuals across all stages of their career, and the K awards ((https://www.nichd.nih.gov/grants-contracts/training-careers/extramural/career) and T32 awards (https://researchtraining.nih.gov/programs/training-grants/T32) offered by the National Center for Complementary and Integrative Health (NCCIH) particularly focus on training complementary and integrative health (CIH) researchers. Several chiropractors and others from the CIH community have benefited from such career awards. These awards require that the individuals are mentored. However what we are increasingly witnessing is that these successful scholars are either lost to the CIH institutions or find that their institutions lack the infrastructure to continue to advance or sustain their research programs and to successfully compete for grants. Many institutions also lack the kind of supporting culture that has been shown to be necessary for successful research programs and individuals [2, 3].

In most health professions, research infrastructure is largely built through research grants. Most CIH educational institutions are funded through student tuition, and historically this has also had to be the source for building their research programs. Few have emerged as NIH grant-funded research programs and those have largely benefited from NCCIH funding, which constitutes less than 1 % of the NIH budget. The number of American chiropractic institutions currently receiving grants is modest and given the increasing costs of sustaining research programs and recent fall in enrollments, there has been a substantial retrenchment in the number of active research programs.

We are left with the situation that at a time when there are more Doctors of Chiropractic with PhDs than at any time in chiropractic history, and while the profession can point to a cadre of active researchers, the chiropractic institutions are increasingly not the home for these scholars. In this article, we consider the possibility that perhaps an institution such as RAND could provide a supporting infrastructure and a supporting culture that could allow CIH researchers to be successful and remain at their institutions.

In previous work Herman and Coulter [4, 5] examined a related policy problem for the CIH professions: the fact that in many policy areas they are not treated as comprehensive healing professions but as modalities. We noted the importance research plays in framing the policies: “Research seems to be focused on the effectiveness of procedures and modalities and only rarely on the health care outcomes associated with receiving care from a member of a particular profession. Guidelines are based on research, and thus, it is not surprising that they also focus on procedures and modalities because research only focuses on modalities, not the professions.” ([4] p506) In medical trials it is common to compare a particular modality to usual and customary medical care which incorporates anything a medical practitioner would normally provide for that patient. So clearly a professional paradigm of care can be the subject matter of research without being reduced to a single modality. We would argue that is equally true for the CIH professions even given the variability in practices even within these professions.

While professions are characterized by having access to a body of knowledge and skills they are also characterized by producing knowledge, not simply consuming it. There are at least two major consequences for chiropractic by not participating in research. The first is that the research agenda will be defined by others resulting in research focusing on modalities, which reinforces the policies that treat the professions as modalities. The second is that its teaching institutions will be seen as technical teaching institutions and not as professional schools. This is particularly problematic in that recent years, chiropractic colleges have moved to becoming universities and have included that in their name. But universities are centers of advanced learning not just teaching institutions. They are by definition, research institutions. Those that teach there are expected to be scholars and those being taught expect to be taught by scholars.

In short, while having individuals doing chiropractic research is necessary but it is not sufficient. If it is being done outside of chiropractic institutions it weakens the institutions as centers of advanced learning. This is the challenge for the US chiropractic institutions.

Although this is not intended as a methods paper we used several approaches to base our conclusions and to ground our recommendations. In our earlier study, we convened two separate expert panels [4, 5]. One panel included representatives from the CIH professions. The second included persons involved in making policy decisions with respect to the professions. Both identified research as a major area for concern. Secondly, both IDC and PMH are experienced reviewers for NCCIH, other NIH, and other funding organization’s research proposals and have seen first-hand the increasing disparity between the quality and sources of the submitted proposals. In the process of developing the proposal described below we have spoken widely to Presidents of 15 chiropractic and nine CIH other institutions and with other leaders in the CIH community and in a limited number of cases shared a written proposal. The discussions were both about the crisis in their research programs and the proposed RAND solution. We are currently planning a meeting at RAND later in September 2019 to launch the proposals with these stakeholders. RAND has undertaken to fund this initial meeting. To date we have found widespread consensus with our interpretation that there is a crisis in CIH research and the nature of that crisis. Although the focus in this paper is chiropractic, what we are proposing is for all the CIH.

In analyzing the situation, it is clear that if the institutions pool their limited talent and resources they might be able to compete, but history has shown that the American chiropractic institutions have not yet been able to do that. However, perhaps through a mediator it might be achievable. We are not suggesting this proposal will solve all the problems and we recognize that outside of the US the situation is different. But within the US it seems to us that without some type of response the situation will get worse not better. The RAND Health program has signed onto this proposal and we are currently approaching foundations to fund it.