The Chiropractic Conundrum: Legitimacy, Identity, Values, Organizational Fit/Misfit and Sensemaking

There’s a conversation I’ve had more times than I can count with chiropractors who are struggling in practice. They’re exhausted. The numbers aren’t where they want them. They feel like they’re constantly justifying their value — to patients, to insurance companies, to family members who ask why they didn’t become a “real” doctor.

Most of the conversation focuses on tactics. Better marketing. Better scripting. Better systems. Better patient education.

But what I’ve come to understand — both from 15 years in practice and now through doctoral-level study in organizational development — is that many of the problems individual chiropractors face in building a sustainable, fulfilling practice aren’t personal failures. They’re inherited ones.

A Profession in an Identity Crisis

Chiropractic was founded in the era of mysticism, and was always largely positioned as an alternative to western medicine. That wasn’t accidental — it was the point. The entire premise of the chiropractic profession that was originally espoused by the 33 principles, is that the body has an innate intelligence that, when free from interference, can express health in ways that drugs and surgery can’t replicate or replace.

That is a fundamentally different framework for understanding health. It’s one that’s based on health and not disease management.

And yet, for 130+ years, the chiropractic profession has largely tried to achieve legitimacy by mimicking the model it was designed to be an alternative to.

The schooling structure mirrors medical education. The licensing and board examination processes follow the medical profession’s model and perpetuates a monotony on licensing and a racket on student debt through student loans. When chiropractic began developing its research base, it adopted the double-blind randomized controlled trial as the gold standard to which it aspired — the same standard designed for pharmaceutical interventions, applied to an art form that is almost impossible to “blind” or replicate with precision.

Someone somewhere decided what “credible research” looked like. And rather than developing its own gold standard — one that actually fits the nature of what chiropractic is — the profession tried to squeeze itself into a framework built for someone else.

This is what organizational theorists call *fit and misfit*. And it matters more than most of us in the profession realize.

When Structure and Identity Don’t Match

Gresov’s (1989) work on fit and misfit within organizational theory explores what happens when the structural choices an organization makes don’t align with its actual nature, values, and goals. The mismatch creates friction — not because the people are doing it wrong, but because the structure itself is working against them.

Chiropractic is a textbook case.

The profession built itself inside the structural model of western healthcare: insurance billing, diagnosis codes, treatment plans measured in visits, outcomes framed in terms of symptom reduction. But chiropractic’s core identity — the subluxation, the adjustment, the vitalistic paradigm, the long-term relationship between practitioner and patient — doesn’t live comfortably in that model.

The result? Practitioners who went into chiropractic to practice a wellness and nervous system-based model find themselves inside a system that rewards different outcomes, measures different things, and constantly signals that what they actually believe about health doesn’t quite count.

That’s not a personal failing. That’s structural misfit.

The Chiropractic Legitimacy Trap

Dutton and Dukerich’s (1991) work on organizational identity and adaptation describes what happens when an organization — or a profession — becomes preoccupied with how it’s perceived by the outside world. The drive for legitimacy starts to drive decisions more than actual values do.

Chiropractic has been fighting for legitimacy since its founding. Chiropractors went to jail for practicing medicine without a license. The American Medical Association ran a documented campaign — eventually found to be an antitrust violation — to systematically discredit and dismantle the profession. That history left wounds that have never fully healed.

And here’s what I’ve come to realize as a member of the chiropractic profession that I believe we all need to understand: the response to that threat largely shaped the profession into what it is today. When your existence is under attack, you do what seems most likely to protect you. You look for credibility in the places the dominant culture tells you credibility lives. You try to prove you belong.

But belonging to a model that doesn’t fit you isn’t safety. It’s slow erosion. And that search for legitimacy when our very creation was to be something different, has left us with the polarized division of vitalistic subluxation based chiropractors advocating for a return and protection of our roots on one hand; musculoskeletal pain based chiropractors pushing for more similarities and belonging in the western health paradigm on the other; and a whole bunch of us caught somewhere in the middle trying to navigate our way through building a practice or career that feels congruent with what brought us to this profession in the first place but caught between the legitimacy rock and a hard place.

What Individual Practitioners Inherit

I built a seven-figure practice by the time I was in my early 30s. On paper, it was a success. Inside, I was losing everything that mattered — my health, my first marriage, my sense of self, my passion and joy for the profession that called me to it because it literally changed my life.

Post major reckoning that came in the form of an insurance audit, two wrist surgeries, the pandemic and an eventual bankruptcy and break from practicing, I spent three years trying to understand what went wrong. I blamed myself. I blamed the business model. I blamed the insurance companies. I blamed my lack of business education. I blamed my own leadership failures.

What I didn’t have the framework to see until recently was this: I had built a practice inside the same legitimacy trap the profession had been building inside of for a century. I was measuring the wrong things, providing care for the wrong outcomes, and trying to prove I belonged in a healthcare system that was never designed for what I actually wanted to offer my community.

Being part of that misfit cycle felt easier than standing on my own. I’ve since realized that belief is a fallacy.

The decisions I made — some of which I deeply regret, and some of which I now understand were inevitable given what I didn’t know — were shaped by those unresolved tensions of fit, misfit, and identity at a level far bigger than me.

Understanding that has been one of the most healing things I’ve done in the last few years. It also gave me the freedom to start exploring my own relationship to my identity as a chiropractor and where my business model and practice goals fit within the greater context of tensions between the role of legitimacy and values in my decision making. Which leads to the next topic in this exploration.

Sensemaking in the Middle of the Mess

Sensemaking. It’s the process by which people — and organizations — make meaning out of ambiguous or chaotic situations. We don’t respond to reality. We respond to our interpretation of it. An interpretation that is influenced by both our internal and external environments.

For individual chiropractors in practice, sensemaking is happening constantly. Every time a patient pushes back on care recommendations. Every time an insurance denial comes through. Every time a colleague builds a practice model that looks nothing like yours and calls it “the right way.” Every time you feel the pull between the wellness philosophy you went to school to practice and the confines of a healthcare system known to be openly antagonistic to entrepreneurship with it’s layers and layers of red tape.

In the midst of this mess, the profession has never given its practitioners a coherent framework for making sense of these tensions. Instead, each practitioner is left to work it out alone, inside a system that signals in a thousand small ways that the alternative paradigm of their roots isn’t quite legitimate enough. And before someone says you just need to go to Dynamic Essentials or another philosophically based room, while helpful for the connection, these spaces aren’t really getting to the root of the reality our profession is educated in and practices in today or helping to make any real change in our professional identity conundrum. If they were, we wouldn’t be where we currently are.

The truth: the mess we do our careers and lives in is an enormous cognitive and emotional load, especially when we leave the safety of “chiropractic island” provided at school and enter the real world.

The Point Isn’t Despair

The point of sharing all of this is not so you feel hopeless about your profession or your practice.

Rather, there’s opportunity in understanding the landscape our profession is operating in that opens the door to building something different.

When you can see the structural misfit clearly, you stop taking the friction personally. When you understand the legitimacy trap, you stop building toward metrics that were never designed to measure what you actually value. When you understand the sensemaking burden, you stop assuming that the confusion, exhaustion and frustration you feel is a character flaw or because you’re doing something wrong.

It isn’t. It’s an accurate read of a genuinely confusing situation.

The work I’ve been developing as a fellow chiropractor and practice owner— and the research I’m pursuing at the doctoral level — is built on a conviction that what’s missing isn’t better tactics, shiny objects or a come to Jesus moment where our profession finally figures out how to want the same things and get along. It’s a different frame entirely.

If you fall against the grain of the sick care paradigm of western healthcare, you can’t build a practice that truly fits you inside a model that was built on misfit. Not sustainably. Not without cost.

But you can build something different, once you can see why the old model was always working against you.

You can engage in the triggering conversations that surround our professional groups and organizations with an entirely new perspective and higher level thinking. And just maybe we’ll start to forge a path forward that brings us closer to a unified profesisonal identity, values and purpose, rather than continuing to perpetuate the quagmire of confusion and warring factions that has plagued us for decades.

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*The organizational concepts referenced in this article draw on the work of Gresov (1989) on fit and misfit, Dutton and Dukerich (1991) on organizational identity and adaptation, and Cohen, March and Olsen’s (1972) work on organizational decision-making under ambiguity.*

References

Cohen, M. D., March, J. G. & Olsen, J. P. (1972). A garbage can model of

organizational choice. Administrative Science Quarterly, 17, 1-25.

Dutton, J. E. and Dukerich, J. M. (1991) “Keeping an eye on the mirror: Image and identity in

organizational adaptation,” Academy of Management Journal, 34(2), 517-554.

Gresov, C. (1989). Exploring fit and misfit with multiple contingencies, Administrative Science

Quarterly, 34, 431-453.