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Chiropractic Practice Building: A Doctor’s Confession and the Report of Findings

“I’ve got to get this off my chest!”

Dear chiropractic practitioner,

Confessions are tough…Real tough. They are painful, awful things. But, sometimes a confession can set the record straight, and I want to give credit where credit is due. Before I talk about my confession though, let me say a few other things first. You may want to sit down.

You know, when I meet people in town they usually say, “Oh, yeah, I know you, you’re Dr. Jones. I’ve seen your posts with that picture of you and the two cute little girls.” Well, I’m the guy on the left. Aren’t they cute? Now do you feel like you can trust me?

Years ago, something happened to me that changed my life forever. And I would love to tell you all about it, but first I need to give you my report of findings.

I’ve correlated the findings of your examination, and I’ve put it into a package that I’m going to review and send home with you, so you’ll know what we found and what we’re going to do to help you. In the next 10 minutes or so I’m going to review what we found, explain what these findings mean, recommend a course of action and discuss the results you can expect in the future. Feel free to ask any questions as we go along.

First a quick review. You’ve come to our website suffering from an inability to recognize your complete lack of effectiveness in the treatment of headaches, ear infections, asthma, or any other condition with the possible exception of acute musculoskeletal pain involving the back. You have difficulty accepting that any treatment you offer which is effective is provided by physical therapists, minus all the ”baggage”, and that nothing you offer which is unique to chiropractic is effective. You are in denial over how the majority of your profession is woefully ignorant of, or exists in a state of denial of, so many of the advancements in modern medicine, like life-saving vaccines, made since chiropractic was invented by D.D. Palmer in 1895.
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Posted in: Chiropractic

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CAM practitioners as primary care providers under the Affordable Care Act: Part 1

Section 2607 (42 U.S.C. Sec. 300gg-5) of the Affordable Care Act (the “ACA” or “Obamacare”) prevents “discrimination” against any health care provider acting within the scope of his or her state license. The provision, supported by the American Chiropractic Association and other CAM practitioners, was inserted, without a hearing, under the leadership of Sen. Tom Harkin. Sec. 2607 is of concern to advocates of science-based medicine due to the broad scope of practice granted chiropractors, naturopaths, homeopaths, acupuncturists and direct-entry midwives under state law, as well as their over-confident view of themselves and their abilities. As we have previously discussed, for example, both naturopaths and chiropractors fancy themselves as primary care physicians able to differentially diagnose any patient with any disease or condition and, in many cases, treat or “co-manage” these patients.

As might be expected, a brouhaha is brewing over just what Section 2607 means. And there is one attempt to repeal it outright.

In all cases of statutory interpretation, the proper starting point is the statutory language itself.

SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

(a) PROVIDERS.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary [of Health and Human Services] from establishing varying reimbursement rates based on quality or performance measures.

In short, while broadly prohibiting discrimination, there are two important limitations. This is not an “any willing provider law” requiring an insurance company to contract with any provider agreeing to the insurer’s contract. And insurers can pay different rates to different providers as long as these rates are “based on quality or performance measures.” (more…)

Posted in: Chiropractic, Legal, Politics and Regulation

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Integrative Medicine Invades the U.S. Military: Part Two

An unfortunate side effect (if you will) of states licensing of “CAM” practitioners is their ensuing insinuation of themselves into the nooks and crannies of the American health care system. Sometimes this is voluntary, such as their inclusion as providers of health care services in medical practices and other institutional settings in the form of integrative and quackademic medicine. Where voluntary action is not forthcoming, CAM practitioners and integrative medicine proponents are not shy about petitioning the state legislatures and Congress to wave the wand of legislative alchemy. “Poof!” and they appear. One example of this is the legislative mandates that their goods and services be covered by private insurance. Another is including CAM providers in publicly-funded health insurance, such as Medicare. And next year we will see the effects of the non-discrimination provisions of the Affordable Care Act begin to unfold.

Two bills currently before the U.S. Congress invoke the magic of legislative alchemy by expanding the availability of CAM to military veterans and funding CAM research at the expense of legitimate research. One deals with chiropractic, the other with CAM in general. As we saw last week, one of this country’s foremost supporters of integrative medicine, Wayne Jonas, M.D., recently testified before the Senate Committee on Veterans’ Affairs in favor of these bills. I think any fair review of his testimony would find it unpersuasive and I hope the Committee will agree.

VA chiropractors

Chiropractors have already forced their way into the Veterans Administration (VA) medical system. For our readers not familiar with the fragmented American health care system, in addition to having a combination of public and private health insurance, or, in some cases, no health insurance at all, we have an entirely separate system of medical care solely for the military that includes its own hospitals and out-patient clinics. Military veterans have had access for some time to chiropractors at a limited number of these VA hospitals and clinics. According to the American Chiropractic Association (ACA), the “military’s medical bureaucracy continues to try to impose new barriers to chiropractic care.” This meant the ACA had to get its supporters in Congress to pass several bills to speed up implementation of the 1995 law requiring the current limited chiropractic benefit. The subtext I read in all of this is that the Veterans’ Administration, or at least those in charge of medical care, was not particularly thrilled with having chiropractors working in their facilities and has dragged its feet in implementing the law.

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Posted in: Acupuncture, Chiropractic, Energy Medicine, Legal, Politics and Regulation

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Integrative Medicine Invades the U.S. Military: Part One

Integrative medicine proponents claim superiority over physicians practicing “conventional” medicine. (Which I will refer to as “medicine” so as not to buy into integrative medicine’s implied claim that medicine can be practiced with two separate standards.) While conceding that medicine is good for treating conditions like broken arms and heart attacks, physicians who purport to practice integrative medicine argue it ignores “the whole person, including all aspects of lifestyle.” Their vision of a new, improved practice of medicine “emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies.””

But, as we know, the practice of medicine already takes into account “the whole person, including all aspects of lifestyle,” is “informed by evidence” and uses “all appropriate therapies.” This includes recommendations regarding diet, exercise, relaxation and vitamin and dietary supplement use, which are often erroneously labeled “CAM.” Medicine appears to be well aware of problems in the current model of health care delivery and is actively seeking ways to improve it. If integrative medical practitioners and their proponents were simply directing their time, energy and resources toward facilitating a better model for delivering health care I suppose no one would have any problem.

But they aren’t. They are claiming rights to an entirely new specialty in medicine. Proponents do this by advancing two dubious arguments. First, integrative medicine alone can deliver on this “whole person” model of care. Second, inclusion of alternative medicine is essential to good patient care.

From a consumer protection standpoint, I find integrative medicine troubling. Proponents are unfairly misrepresenting medical practice as inferior and offering themselves as the solution when there is no evidence that they can deliver on these claims. Unfortunately, despite this lack of evidence, integrative medicine has seized the imagination of public policy makers and legislative bodies. It is included in the Affordable Care Act and continues to metastasize throughout the military health care system, which together will soon control delivery of the vast majority of health care in this country.
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Posted in: Acupuncture, Chiropractic, Clinical Trials, Energy Medicine, Legal, Politics and Regulation

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Six reasons CAM practitioners should not be licensed

States license “complementary and alternative” (CAM) practitioners (chiropractors, naturopaths, acupuncturists/TCM practitioners and homeopaths) via the magic of “legislative alchemy.” Ironically, licensing statutes are enacted based on the states’ constitutional power to protect the health, safety and welfare of the public. Yet these CAM practice acts actually increase public vulnerability to unsafe and ineffective health care practices.  It is, in short, a bad idea.  (A point we’ve discussed many times on SBM.) Here are six reasons why.  Feel free to add to the list.

1. Practice acts grant CAM practitioners a broad scope of practice, including legalization of scientifically implausible and unproven (or disproven) diagnostic methods, diagnoses and treatments.

Like medical doctors, dentists and nurses, CAM practitioners must practice under licensing legislation, also referred to as a practice act. Otherwise, they risk prosecution for the unlicensed practice of medicine or other licensed profession unless they are exempted by one of the so-called “health freedom” laws, which basically give everyone the right to practice medicine.

Chiropractic practice acts incorporate the absurd notion that patients are suffering from “subluxations” that adversely affect their (or their children’s) health. Acupuncture practice acts are based on the equally absurd notion that the body contains “meridians” which, when blocked, cause ill health, but can be relieved by sticking people with needles. Naturopaths can diagnose and treat conditions they invented out of whole cloth, such as chronic yeast overgrowth, ubiquitous “food sensitivities,” and adrenal fatigue. Homeopaths can treat patients with expensive little bottles of water. (You can find out much more about these CAM practices in the pull-down menu accessed via the “Categories” tab to the right of this post.)

Although there are exceptions, most practice acts grant CAM providers the right to diagnose and treat any patient, no matter what age or physical condition, suffering from any disease or condition, as long as the disease or condition is described in the terms of the practice act and the treatment is within the scope of practice. This is perhaps best illustrated by examples. Suppose a patient sees a chiropractor for vertigo. The chiropractor is legally allowed to diagnose the cause of vertigo as one or more subluxations of the spine and to treat the patient with adjustments. What if the patient sees an acupuncturist? If the acupuncturist diagnoses blockage of “qi” as the cause of vertigo and performs acupuncture to unblock the “qi,” the acupuncturist has done nothing outside his scope of practice. And if the patient sees a naturopath? The naturopath is free to diagnose, for example, “toxins” as the cause of the vertigo and proceed to treat these toxins with colonic irrigation. How about a homeopath? Same result: the patient is treated with what is essentially water. None of this will address the patient’s vertigo but it is all perfectly legal. (more…)

Posted in: Acupuncture, Chiropractic, Health Fraud, Homeopathy, Legal, Naturopathy, Politics and Regulation, Traditional Chinese Medicine

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Gyrostim and the Infrastructure of Quackery

It’s frustrating to read yet another story of the process of developing a potential new medical treatment derailed by the current infrastructure of quackery that we have in this and other countries. This is one of the unmeasurable harms that results when pseudoscience is given regulatory, academic, and professional legitimacy. The press then celebrates the nonsense that results.

The basic story is often the same, with a few variations. First, however, let me describe what should happen when someone comes up with an idea for a new medical treatment.

Background research – The first step, whether the innovator is within or without the medical community, is to familiarize oneself with existing research. Is the idea plausible, has it been investigated before, are there any similar treatments that can act as a guide to predicting how this new treatment will work?

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Posted in: Chiropractic, Neuroscience/Mental Health

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Whack em hard/Whack em once and Stroke

There is no satisfaction in hanging a man who does not object to it.
~ George Bernard Shaw

I work in a 5-hospital system and many of us practice at several hospitals. The residents rotate through at least three of the hospitals and the peripatetic nature of health care allows word of curious cases to percolate through the system.  My current resident mentioned that there was a case of a vertebral artery dissection in a young female shortly after chiropractic neck manipulation.

Man, that’s awful. Is she doing OK?

Evidently there were no permanent neurologic sequelae. She dodged that bullet. Or perhaps that noose, as I once calculated that the force of a neck crack is about 40% that of hanging by the neck and it has the same pathologic changes if it goes wrong. Every time I see a death in the movie where the neck is twisted to break it, I think chiropractic, although some tolerate it better than others.

I have not written on CNS events related to chiropractic since 2008, although the topic has been covered by Dr. Hall.  I still suspect that occasionally there is a perfect storm of bad luck, the forces are perfectly aligned in a susceptible patient and they get an embolic stroke or a vertebral artery tear.
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Posted in: Chiropractic, Clinical Trials

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Dr. Who?

If the “Health Freedom” movement has its way, everyone in the United States will be able to practice medicine. It may be quack medicine but that doesn’t seem to bother them. Short of that, chiropractors, naturopaths and acupuncturists are aiming to reinvent themselves primary care providers and even physicians. As David Gorski pointed out, this will reduce medical doctors to just another iteration of physician, the “allopathic” type, equal in stature to the chiropractic, naturopathic and acupuncture types. These “physicians” already call themselves “doctor” (e.g., “Doctor of Oriental Medicine”) and claim to graduate from four-year “doctoral” programs. This despite the fact that their schools operate outside the mainstream American university system and avoid some of the basics of typical graduate programs, such as entrance exams, as well as the extensive clinical training required for medical doctors.

Consumers are confused by all of this, and who wouldn’t be? In 2008 and 2010, surveys done for the American Medical Association by outside firms revealed that many patients did not know the qualifications of their healthcare provider. The comparisons were between allied health professions (e.g., audiologists and nurse practitioners) and medical doctors, but chiropractors were included. In 2008, 38 per cent of those surveyed (n=850) thought chiropractors were medical doctors, although that dropped to 31 per cent in 2010. Still, we are talking about roughly one-third of the survey participants.

The surveys also asked about the use of the term “physician” and confusion in advertising materials.
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Posted in: Acupuncture, Chiropractic, Health Fraud, Legal, Naturopathy, Politics and Regulation, Science and Medicine

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Veterinary Chiropractic

People are sometimes surprised to learn that all the heavy hitters of alternative medicine, such as acupuncture, chiropractic, homeopathy, etc., are inflicted on animals as well as humans. I’ve written about veterinary homeopathy, and the associated manufactroversyin a previous post, and today I thought I’d take a look at veterinary chiropractic.

The Players

In most states, chiropractic is defined in terms of treatment of humans and chiropractors are thereby licensed only to treat humans. However, there are a variety of ways around this for people who want to subject their animals to this therapy. Some chiropractors will simply treat animals and ignore the fact that it isn’t technically legal for them to do so. And some veterinarians will take one of the many training courses available in animal chiropractic and then employ it as part of their practice of veterinary medicine. A previous SBM article has discussed the lack of consistency or legitimate scientific content in most of these courses.

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Posted in: Chiropractic

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Chiropractic and Sudden Infant Death Syndrome

As a pediatrician caring for hospitalized children, I deal with fear on a daily basis. My day is saturated with it. I encounter fear in a variety of presentations, with parental fear the most obvious but probably least impactful on my management decisions. I do spend a lot of time and mental energy calming the fears of others but more managing my own, both struggling to prevent it from biasing my thought process and harnessing it as a productive motivational force. I devote a significant amount of effort towards teaching residents and students the practice of inpatient pediatric medicine and fear can be a valuable teaching tool when used appropriately.

So I admit that I take advantage of fear to a certain extent in my practice. Most pediatricians do. Maybe we all do. Proper informed consent, for instance, must include potential poor health outcomes related to medical intervention or the refusal of them. I accept that fear is an impetus for seeking medical care. Parents should be afraid of poor health outcomes from vaccine-preventable illnesses, for example. They should be made aware of the repercussions of poor adherence to home asthma management or of not placing their child in a proper car seat every time they put them in a car. Fear can serve the greater good.

But there is a difference between these unavoidable aspects of science-based medical care and the abuse of fear by practitioners of irregular medicine.

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