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An Ethnography
of a Chiropractic Clinic

Chapter 1: Introduction

© 1975
James B. Cowie, PhD
Julian B. Roebuck, PhD

The following is an ethnographic analysis of a chiropractic clinic primarily from the points of view and social meanings of those actors in this behavior setting: the chiropractor himself, his full-time assistant, and a wide representation of his patients. As will be demonstrated, the chiropractor, although his profession is now legal (licensed) in every state, continues to endure a deviant status in American society. Such marginal deviance demands careful analysis by sociologists.

This study is unique in that the limited research done on the chiropractor has yielded data gathered from an assumed objective stance. Furthermore, the methodology employed hopefully will add to our understanding of the chiropractor and other marginally deviant social positions.

Traditionally, part of the subject matter of ethnographers has been the study of native theories of illness and healing practices. As McCorkle [1] has pointed out, "growing interest in the field of culture and medical care has led to intensive work on the nature and meaning of "folk medicine." Deviant, non-Western medical theories and practices persist in some populations in the United States, including upper-middle-class Americans, usually in the form of spurious nostrums, devices, and treatments [2]. The question has been raised as to whether or not these competing systems actually satisfy patient needs which are incompletely fulfilled by the medical establishment [1].

Many contemporary students of deviance [3] are beginning to recognize the value of studying the phenomenon of deviant behavior in more conventional contexts (e.g., the "establishment" physician, the physically handicapped, the institutionalized mentally ill, and the dying patient) in contrast with the classical foci upon the obviously outcast, e.g. delinquents or drug addicts).

The most influential of the competing health care systems in the United States is chiropractic. Chiropractic rejects the germ theory of disease -- the contemporary view held by Western medical scientists that most illnesses have as their cause some variety of microorganism -- and replaces it with a fundamentally unique concept (spinal malalignment) of the cause of all illness. This health care system began in 1895 in Davenport, Iowa, and since then has become firmly established in this country. Its. practitioners are trained in chiropractic colleges and are joined together as members of several organizations. In this sense it may be considered an organized discipline.

Although chiropractors represent the largest organized body of marginal health practitioners in the United States (13,729 listed in the 1970 census), little systematic study of this form of health care has been undertaken. Leis, in an attempt to generalize to the professionalism of various occupational groups, examined the emergence of chiropractic as a professional organization [4]. Drawing a sample of 178 New York State chiropractors, Leis tested eight hypotheses, all of which were designed to objectively measure their professional characteristics. Focusing upon the division in the chiropractic profession (discussed in Chapter 2), this study also sought to examine the problem of loyalty in this profession since the chiropractor must pledge allegiance to one of the two competing philosophical camps.

Sternberg, through the use of direct observation, interviews, and lengthy questionnaires, sought to examine the socialization of students attending chiropractic colleges. Evidence which documented the internalization of the stigma attached to chiropractic by society was presented. The stigma was shown to be a central feature in the chiropractic subculture at these colleges [5].

Both of the studies cited above have attempted to generalize from chiropractic as a profession to professionalism trans-situationally. Very little work, on the other hand, has been done on the chiropractor at work; the main exception is the initial systematic examination of chiropractic by Wardwell [6]. In Wardwell's Social Strain and Social Adjustment in the Marginal Role of the Chiropractor, a Parsonian functional approach was employed to analyze the general phenomenon of strain reduction in the larger social structure. Here again, however, the goal was to generalize about the profession as a whole and even beyond to similar marginal roles.

Prior to the publication of that study, no study of the chiropractor in his natural setting had been made. The objective of the present work is to add to our information.

LABELING THE CHIROPRACTOR AS DEVIANT

As Roebuck and Hunter have indicated, contemporary students of deviant behavior "stress the importance of labeling and sanctioning processes and social roles in determining who or what is deviant." [7] Deviant behavior is behavior that people so label [8]. Roebuck and Hunter have designated five formal, rulemaking, labeling and sanctioning bodies within the health care area: (1 ) the American Medical Association, (2) federal agencies, (3) the scientific establishment, (4) commercial associations, and (5) state agencies [7]. The following extracts have been selected from public statements made by representatives of the labeling bodies.

The American Medical Association House of Delegates adopted a statement on chiropractic in 1966:

It is the position of the medical profession that chiropractic is an unscientific cult whose practitioners lack the necessary training and background to diagnose and treat human disease. Chiropractic constitutes a hazard to rational health care in the United States because of the substandard and unscientific education of its practitioners and their rigid adherence to an irrational, unscientific approach to disease causation.

In 1868, the U. S. Department of Health, Education, and Welfare submitted to Congress the following conclusion concerning chiropractic:

There is a body of basic scientific knowledge related to health, disease, and health care. Chiropractic practitioners ignore or take exception to much of this knowledge despite the fact that they have not undertaken adequate scientific research. . . . The inadequacies of chiropractic education, coupled with a theory that de-emphasizes proven causative factors in disease processes, proven methods of treatment, and differential diagnosis, make it unlikely that a chiropractor can make an adequate diagnosis and know the appropriate treatment [9].

The Scientific Establishment -- Commenting upon an article by McCorkle [1] which objectively dealt with the chiropractic in rural Iowa, Lindsmith and Strauss have pointed out:

even this sympathetic anthropologist thinks of chiropractic as a "deviant theory of disease and treatment" -- using modern medicine as his baseline of comparison. . . . Likewise, in a recent book of readings in the Sociology of Medical Institutions (1966), a section is entitled "Marginal Healers." The editors assume that there will be the eventual triumph of scientific medicine [over chiropractic]. [10]

It is ironic that even Roebuck and Hunter, who have delineated the labeling bodies discussed in this section, have contributed to the deviant image of chiropractic by publishing an article which designates it as such to a scientific reading public.

In 1970, the Consumer Federation of America, representing 184 local, state, and national consumer-oriented organizations with millions of members throughout the nation, expressed concern that:

Studies of chiropractics [sicl have not produced evidence of the scientific validity of chiropractic theory and practices, [and] . . . is gravely concerned that chiropractic services would needlessly expose [patients] to potential health hazards [11].

The Medical Society of the State of New York stated:

Chiropractic is an unscientific cult whose practitioners lack the necessary training and background to diagnose and treat human disease, which is the practice of medicine. . . . Medicine, the allied professions, the voluntary health agencies, and informed people everywhere must be united to thwart the efforts of a common enemy whenever and wherever it rears its ugly head. Against the quack, our best defense is an attack [12].

To Roebuck's five formal sanctioning bodies a sixth category could be added: Private interest groups. An AFL-CIO "Fact Sheet" stated:

Care of patients should only be entrusted to those who have a sound scientific knowledge of disease and whose experience and competence render them capable of diagnosing and treating patients by utilizing all the resources of modern medicine. Since neither chiropractic theory nor the quality of chiropractic education equip chiropractors to do this, the AFL-CIO opposes . . . chiropractic [13].

In 1969, the National Council of Senior Citizens stated:

Chiropractic treatment, designed to eliminate causes that do not exist while denying the existence of the real causes, is at best worthless-and at worst mortally dangerous [14].

The above public statements made by persuasive labeling groups illustrate that chiropractors endure a deviant or at least marginal role in the United States today. As Roebuck has noted, these powerful sanctioning organizations operate at different levels in the social order, affecting various segments of the population [7]. Furthermore, not all of these formal groups agree upon common definitions nor do they present to the public a unified and consistent view of chiropractic. It is obvious that some persons and groups reject the deviant label and/or the affixed sanction imposed by these bodies.

The recent interest in medical sociology has generated a need for additional knowledge about limited, marginal, and quasi-practitioners of various kinds. In addition, there seems to be a growing interest in the powerful institutions -- for instance, the American Medical Association -- as labelers of deviant roles (in this case, that of the chiropractor). This type of inquiry is reflected in the work of Wardwell [15], McCorkle [1], Lindesmith and Strauss [10], and others.

ORIENTATION OF THE STUDY

Ball, in his often cited article "Ethnography of an Abortion Clinic," notes that the study of deviant behavior has long suffered from a lack of primary data [16]. Most analyses depend upon data gathered from the actual social phenomena. Both of the official statistics and the self-reports by participants removed from the theater of action do not represent an unbiased sample of actors, actions, or social organization. (For an excellent discussion of the limitations of official statistics as a data source, see reference 17.) Techniques similar to those advocated by Goffman [18], Becker and Geer [19], Cavan [20], Blumer [21], Denzin [22], Ball [16, 23], and Roebuck and Frese [24] represent an alternative method to the study of deviance. Ball proposes that we go "directly to the unconventional actors and their subcultures; it is only with such procedures that the natural context of deviance can be studied without the skewedness typical of the usual sources of data." [23:295]

This type of research endeavor is a direct outgrowth of the Chicago school of symbolic interactionism as it was set forth primarily in the work of George Herbert Mead [25-27 and especially 28]. It is not necessary to review extensively the entire history and range of this approach. Herbert Blumer, in his excellent work Symbolic Interaction, has summarized the three premises of symbolic interaction:

In light of these principles, the present study is specifically concerned with a description of the practices exhibited by all actors in a chiropractic behavior setting (hereafter referred to as the Clinic) which exemplify their definitions of that situation. It is assumed that these actors -- both patients and staff -- have social definitions of the situation which are evidenced by their conduct (premise 1). Consequently, in the present study it is assumed that these actors create and maintain rationalizations for their conduct in order to make that conduct presentable to themselves and to others (premise 2). (The assumption is based upon Mead's concept of self, which implies that the human being has the capacity to respond not only to the gestures of others but to his own. In referring to the human being its having a self, Mead means that the actor in any setting may act socially toward himself as well as toward others. For a concise summary of this process, see reference 29:15-18.) They present to themselves, as well as to others, a construction of the behavior setting through their actions (premise 3). Thus, the main concern of this study will be an analysis of a chiropractic clinic defined in terms of the interactional patterns characteristic of' that behavior setting.

THE METHODOLOGY OF SYMBOLIC INTERACTIONISM

Denzin, in his book The Research Act [22], has outlined a series of methodological principles which are required by the interactionist perspective. Among these, several are especially relevant for present purposes. (For a complete discussion of these principles see reference 22:7-29.)

First, the symbolic nature (definitions) of social situations and the interaction taking place within them must be considered together if the investigation is to be complete. Other research methods, Such as the exclusive use of questionnaires and attitude surveys, fall to capture the emergent and novel aspects of human behavior.

Second, if the reflective nature of self -- the process of analyzing one's own being -- is to be captured, the researcher must assume the standpoint of each actor in the ongoing social situation and view the role-taking process as engaged in by each of those actors.

Furthermore, when the investigator links the definitions of situations and the self definitions of actors within those situations, both must be viewed as relative to those social relationships which furnish him with those symbols and conceptions. Loosely associated with this principle is the observation that society provides for its members a variety of behavior settings within which various behaviors occur.

Interactional methodology must, therefore, take into account these situated aspects of human behavior. Moreover, both stable (standing patterns) and processional (innovative or disruptive) behavior within these behavior settings must receive careful attention.

Finally, the very act of social research must take the form of symbolic interaction involving the attempt to reach the level of consensual meanings in the social situation. Central to this interaction is a concept within the setting which enables the researcher to participate in and organize for himself the interaction he is witness to. Thus, both the concept and the methodology act as empirical sensitizers to be employed as observational techniques based upon the premises of symbolic interactionism. Blumer, in a discussion of the topic of sensitizing concepts, states:

It gives the user a general sense of reference and guidance in approaching empirical instances. Whereas definitive concepts provided prescriptions of what to see, sensitizing concepts merely suggest directions along which to look [21:14].

The central concept employed in this study is the behavior setting as the unit of observation, and the methodology, that of participant observation, both of which are defined below.

THE BEHAVIOR SETTING

As noted by Gump, a behavior setting may be defined as consisting of three elements:

The total configuration of the behavior setting is thus defined as consisting of more or less stable elements that actors rely upon and use as the basis of action, as well as the organization of these elements being particularly unique to the setting [31]. In short, the present study will center on the discovery of the practices exhibited by the actors in the chiropractic behavior setting whereby they present to one another the setting as they respond to it situationally.

It could be construed that for the symbolic interactionist there is all inherent danger in distinguishing between behavioral and nonbehavioral elements: all perceived objects, according to Mead, are, by definition. relative plans of action and as such are inseparable from the temporal and special context within which they are perceived. Although ecological psychologists have recently recommended studying the physical aspects of a setting completely apart front the behavior which takes place within it (see, e.g., reference 32), this seems counter to the traditional interactionist approach. However, a modification of Gump's model as it is used here is defensible on the grounds that it emphasizes the dynamic interplay between heuristically distinguishable elements. The main modification of Gump's model involves the inclusion of so called rules. Although not posited here as causal elements in an explanatory sense, the actors in the setting, particularly the practitioner, repeatedly referred to and spelled out for me the "rules of the game" which is why they are included here.

Focus

While the totality of features and interactional patterns within any behavior setting may be subject to scrutiny, in the present study the following specific foci are considered essential:

STUDY DESIGN

Participant Observation

In order to achieve the goals outlined above, an extensive use of the participant observation technique was required.

Initially, I [James Cowie) had been a patient participant in the Clinic. Although the primary reason for seeing the practitioner had been one of curiosity, nevertheless I had been suffering from chronic spinal discomfort for which no relief had been afforded by the establishment physicians. During these visits, I became acquainted with the practitioner and his wife, who was his full-time assistant. Moreover, friendly relationships were also established with various regular patients in the Clinic.

After having decided to study the Clinic as a deviant behavior setting, I asked the practitioner if he would employ me as his part-time assistant. Since he had young children and his wife wished to spend more time at home, he readily accepted. At this point in time I shifted from what Natanson calls the "natural stance" of the native's position [33] to that of the interactional analyst (participant observer), while carrying out the duties of assistant. These duties involved general office work, which included the duties of a receptionist and telephone operator.

The chiropractor knew that I was in graduate school and had an interest in "social medicine." He was under the impression, which was largely fostered by himself, that I was considering chiropractic as a profession. For this reason he began to train me in the techniques of chiropractic as well as chiropractic public relations. This training procedure is not unusual because one of the major concerns of the chiropractor is the recruitment of persons into the profession so that "the world might become aware of this great cause." Application forms for admission to the Palmer College of Chiropractic were on display in the waiting room.

As the chiropractor's assistant, I was allowed direct contact with all actors in the setting. The position of assistant was advantageous because "professional," informal communication became possible with all patients seeing the practitioner. Moreover, "backstage" data [18] were also easily available and direct quotations were recorded as accurately as possible.

Comparative Data Sources

As indicated by Denzin, no single method will ever meet the requirements of the interactionist's frame of reference as set forth above [22]. Participant observation, in this case coupled with the sensitizing concept of the behavior setting, must be supplemented with other data sources. Participant observation, as one methodological technique, reveals only certain aspects of empirical reality and, for such reasons, must be supported, ideally, with multiple methods. Denzin has termed this procedure, "triangulation."

Utilizing the triangulation procedure to check the reconstruction of the setting and a patient typology, information from six data sources was compared and contrasted to reveal any discrepancies:

Participant Observation. This main data source, as described above, constitutes the core ethnography.

Unobtrusive Observation. It might be objected that the continual presence of a participant observer could disrupt the normal flow of interaction in social situations. This was not considered to be a central problem in the Clinic, the role of assistant being an integral part of the performance team. It was felt that unobtrusive observation would serve to cross check statements made by various actors in the setting. The problem of whether an informant actually does what he says he does is an obvious difficulty in any research endeavor.

While carrying out my duties in the Clinic, I had the continuous opportunity to unobtrusively overhear conversations among the patients in the waiting room. Furthermore, I was able to record most of the dialogues which took place between the practitioner and his patients while not being physically present. Finally, most of the telephone conversations of the practitioner were noted without actually participating. As far as could be determined, never was there any attempt to hide any actions or interactions from my observations." It should be added that at no time did I attempt to hide the fact of my observations from either the staff or the patients.

One of the earliest and most significant works dealing with unobtrusive measures is Webb's Unobtrusive Measures: Nonreactive Research in the Social Sciences [34]; see also Denzin [22:260-293]. As Denzin has indicated, one of the most perceptive applications of the unobtrusive method can be found in Goffman's studies of face-to-face interaction [35].

Unstructured, Open-Ended Interviews with the Practiitoner. Toward the end of the three-and-one-half-month period of my employment as an assistant, I informed the pracitioner that I was interested in writing about my experiences in the Clinic in the form of a sociologic study. I was careful to point out that he and all the actors in the Clinic would remain anonymous. He was interested in my recorded observations, which were related to him orally, and expressed a desire to help.

These interviews lasted an average of one to two hours a day for a period of two weeks, and they took place in his private office. For the most part, he concurred with the observations of this study.

Interview with The Full-Time Assisrant (Wife). Although his wife was present with the pracitioner during three of the interviews described above, it was also possible to interview her alone. These interviews, however, were sporadic, usually taking place during those times when the practitioner was occupied.

It should be noted that of all the data sources listed here, the wife contributed the least original information. This was due to the following reasons: she was a full-time assistant only in the early days of the research project and, although she was primarily responsible for my training as assistant in the beginning, she appeared in the Clinic less often after the first two weeks; second, her conception of chiropractic, her husband's professional experience, and her definitions concerning the Clinic and the patients who came to it generally agreed with those of her husband. This of course is also very significant. During the practitioner's chiropractic schooling, his wife became well aware of the type of training he received. She seemed quite knowledgeable concerning chiropractic topics. At the Palmer College of Chiropractic, where the practitioner received his degree, wives of students are encouraged to participate in their husband's practice. Chiropractic schooling is a major social event involving class activities, parties, friendship sessions with wives participating freely. At the chiropractor's graduation, his wife, along with the other wives, received a "GHT" (Getting Hubby Through) degree.

Interviews with Patients. As with the interviews which took place with the practitioner and his wife, patient interviews were open-ended, unstructured, and took place during the last days of the study. Patients were informed of my status as a researcher.

A total of thirty-one patients were interviewed, and all interviews took place in the waiting room. At times other patients were present, although many were alone when interviewed. Neither the practitioner nor his wife was ever present. The time spent with each patient ranged from ten to forty-five minutes.

A certain amount of selection was necessary to assure the inclusion of patients who had already been typed by the practitioner. The sample was composed of fifteen regular patients, ten problem patients, and six who had been typed as one-timers. These patient types will be discussed in detail in Chapter 5, which deals specifically with the practitioner's typology.

Interviews with Other Chiropractors. Extensive interviews were obtained from three other chiropractors. They varied in terms of purpose, duration, and the times at which they were conducted during the course of the study.

Before my employment in the Clinic, I visited a chiropractor who practiced in the same building. Although I had been a former patient of the first chiropractor, my visits to his office were prompted primarily by curiosity. After a one-month period -- during which I saw him twice weekly -- I became familiar with the routine of a chiropractic office.

When the chiropractor later moved to a nearby city, he rented his office to the practitioner who was eventually to employ me. I continued my contact with the first chiropractor and often spoke to him on the telephone. The Clinic's practitioner and I questioned him in detail about various practical aspects of his former practice; for instance, there were questions concerning, various patients, the equipment in the office, and rental procedures. Unfortunately, a dispute occurred between the two practitioners, and a follow-up interview at the conclusion of this study became impossible.

Approximately one month before the study was terminated, I visited the only other chiropractor in the town. This practitioner defined himself as a mixer chiropractor. As will be seen, mixer chiropractors strongly disagree with straight chiropractors (and the Clinic's practitioner was a straight chiropractor) about treatment procedure.

Since the two practitioners knew each other casually, each was very interested in the practice of the other. For this reason, it was possible to obtain an extensive one-and-one-half hour interview with the mixer practitioner. Tile interview was conducted in his office during his regular office hours.

After the study in the Clinic was terminated, I visited, again as a patient, a third chiropractor whose practice closely resembled the practice of the Clinic's practitioner. Since he was also a "straight" chiropractor, he shared a common philosophy. Furthermore, the physical appearance of his clinic, the size of his staff, and the volume of his business were quite similar. His practice was located in a town over a hundred miles from the Clinic in this study; he knew of the Clinic's practitioner only by name.

After being processed as a new patient and receiving a spinal adjustment, I discussed my prior employment in the Clinic, revealed my intentions to write a study based upon those experiences, and asked him to comment on my oral observations, The interview session lasted a little more than one hour. Again, it took place in his office during his regular office hours

The interviews with the other chiropractors served as sensitizers [21:14]. The first straight chiropractor increased my awareness of the practical aspects of running a chiropractic office; the mixer practitioner drew attention to the subtleties of chiropractic philosophy. Both chiropractors served to orient my research within the Clinic and to open new paths of inquiry.

The last chiropractor helped summarize the entire study because he reviewed with me (as did the Clinic's practitioner) my general findings. Also, the patient typology, which had been constructed for me by the practitioner in the Clinic, was examined by the third chiropractor and his observations were noted.

Although it is not the purpose of this study to generalize its findings to all chiropractic clinics, there are reasons for assuming, to a limited extent, trans-situational qualities:

PATIENT TYPOLOGY

A typology of patients is presented in Chapter 5. The typology was constructed around the characteristics of patients as perceived, organized, and expressed by the practitioner in the Clinic. These types include those persons who came to the Clinic on a regular basis, those who were sporadic in their visits, and those who failed to continue treatment.

The question of patient conversion to this particular deviant form of health care practice hopefully will prove valuable in the study of conversion to other forms of marginal philosophies and/or behavior patterns. (See John Lofland's Doomsday Cult: A Study of Conversion, Proselytization and Maintenance of Faith [36].)

The final chapter constitutes a general summary, review, and a discussion of the implications of the entire study. Suggestions for future research are made.

REFERENCES

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