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Archive for Chiropractic

The DC as PCP? The battle continues

Chiropractors are trying to rebrand themselves as primary care physicians, a topic both Harriet Hall and I have addressed (here and here) on SBM.  Toward this end, they are seeking the expansion of their scope of practice, via the magic of legislative alchemy, to include the prescription and administration of drugs.  Not drugs that any self-respecting M.D. would use, but drugs nonetheless.  That effort succeeded to an extent in New Mexico.  Recently Colorado got into the act.  Other states have followed suit.

Chiropractors have claimed from the very beginning they are primary care physicians. Chiropractic was born in 1895 with the notion that virtually all diseases could be resolved with chiropractic treatment.  This was Daniel David Palmer’s original contention, that the interruption of “nerve flow” by “subluxations” caused disease which could be remedied by spinal adjustment to restore the flow, thereby allowing the body to heal itself.

State chiropractic practice acts have always given chiropractors a broad scope of practice which allows them to diagnose and treat virtually any condition as long as they can squeeze the treatment into the “chiropractic paradigm.”  If they can pretend the condition is amenable to chiropractic treatment via the detection and correction of subluxations, they can diagnose and treat it legally.  This is how they are able to claim, falsely, that asthma, allergies, colic, and many other health problems can be resolved by chiropractic care.  This is how “straight” chiropractors still practice.

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Posted in: Chiropractic, Health Fraud, Herbs & Supplements, Homeopathy, Legal, Politics and Regulation, Vaccines

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SCAMlandia

I quite like Portlandia. I find it funny and it captures a part of Portland. I recognize large swaths of the city’s culture in the show. Other representations of the city I recognize less. Sunset publishes beautiful photographs of the NW, but when I look at the photos I think, that section of the city never looks that good. It is quite wonderful how Photoshop can improve on reality.

Like most major cities, Portland has a monthly magazine, Portland Monthly. The city represented in that magazine is mostly alien to me. I look at the advertisement, the articles, the photographs, and wonder when did Portland become a city with an average 7 figure income? The Portland in which I grew up and currently live is rarely found in the pages of Portland Monthly. If you are extremely well to do, I suppose you are in the demographic Portland Monthly. But when I flip through the pages of the magazine, I see little I recognize, but I have never completely abandoned the hippie/grunge aesthetic of my younger days.

Every January they have the best Doctors issue* and this year, for the first time, they offer The Portland Alternative Medicine Guide. Well, less a guide and more an extended infomercial filled with ‘facts’ that deserve the quotes. (more…)

Posted in: Acupuncture, Chiropractic, Dentistry, Energy Medicine, Homeopathy, Legal, Naturopathy, Politics and Regulation, Science and Medicine, Traditional Chinese Medicine

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Andrew Weil Flirts with Evidence Based Medicine

Andrew Weil, MD, pops up quite frequently on SBM, most recently in this entry by Harriet Hall, so I will not spend much space introducing him. An excellent biography and critique of Dr. Weil was written by Arnold Relman, former Editor of the New England Journal of Medicine. It is over a decade old, but contemporary to some of the events described in this post, and still quite relevant.

Suffice it to say that Dr. Weil is one of the most successful and well recognized popularizers of alternative medicine. He has authored or coauthored dozens of books. His website sells everything from baby pacifiers to vitamins to breakfast sausages, packaged bearing his name and/or visage. He is an altmed rockstar. He has been a key player in the branding of alternative medicine. In particular, been an advocate of “integration” of traditional and alternative medicine. He has created and exported residency training programs, and more recently proposed board certification in integrative medicine.

I recently read a book entitled On Being Certain: Believing you are right, even when you’re not, by Robert Burton, nicely-reviewed and recommended by Harriet Hall. In his book Dr. Burton excerpted an interview with Dr. Andrew Weil, pointing out Dr. Weil’s profound certainty about the effectiveness of a particular alternative treatment in spite of contradictory evidence. Dr. Hall also discussed this section of the book in her review. I found the excerpts fascinating and decided to delve more deeply into the interview. I also found another interview with Dr. Weil relevant to his ideas about evidence.

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Posted in: Chiropractic

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Chiropractic “Research” on Tourette Syndrome: The Trouble with Case Reports…..

I can think of few conditions with clinical features more ideal for establishing a pattern of abuse at the hands of practitioners of so-called alternative medicine than Tourette syndrome. Tourette syndrome (TS), which first manifests itself in early childhood in the overwhelming majority of patients, is a neurological disorder with infamous motor and vocal manifestations and a troubled past. Historically the condition was blamed on everything from emotional disturbances to outright faking to demon possession. But over the past few decades it has increasingly been recognized as a primarily organic disorder caused by negative genetic and environmental influences on areas in the brain which control movement and behavior.

I have a particular interest in Tourette syndrome, not just because I am a pediatrician but because I was diagnosed with the disorder at the age of seven. I have been lucky in that my symptoms, after a few rocky years in middle school and early high school, have been fairly mild. It is obvious to most people that I have a movement disorder, but it has never impacted my ability to function in society and succeed in my chosen profession of pediatric medicine. In fact, I often think of my Tourette’s as a positive aspect of my life, believing that it helped shape who I am as a person. I feel that it has helped instill in me positive personality attributes that are beneficial in the practice of medicine, such as empathy and compassion.

Patients that would have been institutionalized a hundred years ago, or worse as you go farther back in time, are now treated based on scientific advances in neuroscience and pharmacology, typically very successfully — that is if they manage to avoid involvement with quacks and charlatans. A 2009 survey of TS patients, or parents of patients with TS, revealed that nearly two thirds partake in alternative therapies with no proven benefit.

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Posted in: Chiropractic, Neuroscience/Mental Health

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Following the Guidelines of Science: A Chiropractic Dilemma

Preamble: When my book Bonesetting, Chiropractic, and Cultism [full text] was published in 1963, renouncing chiropractic vertebral subluxation theory and recommending that chiropractic be developed as a subspecialty of medicine in the treatment of mechanical-type back pain, the chiropractic profession refused to acknowledge or review the book. I was labeled “an enemy of chiropractic.” If it had not been for the support I received from the science-based community, I might have had doubts about my mind set and my motives. Favorable reviews by members of the science-based community sustained me over the years; for that, I am deeply grateful. Today, still unheard by the chiropractic profession, the message of my Bonesetting book remains relevant in describing the problems of chiropractic. Although out of print, the entire book can be read online on Chirobase.org.

 

The Aftermath of Bonesetting, Chiropractic, and Cultism, 1963

In view of the absence of any extensive histories of chiropractic, this book has a place in medical collections and reference libraries. ─ Eric Meyerhoff, Director, The Medical Library Center of New York, N.Y.C., Library Journal, February 1, 1964

In regard to your recent application for membership in the American Chiropractic Association and insurance in the National Chiropractic Insurance Company, please be advised that the ACA membership committee has rejected your application. ─ H.W. Pruitt, D.C., Executive Secretary, American Chiropractic Association, May 17, 1965

I purchased your book some months ago on Bonesetting, Chiropractic, and Cultism. I found it to be a most intriguing and enlightening publication which has been of value to me in some of my own studies in medical anthropology. ─ James G. Roney, M.D., Ph.D., Stanford Research Institute, November 11, 1965

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Posted in: Chiropractic

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The War Against Chiropractors

In 2011, chiropractor J.C. Smith published The Medical War Against Chiropractors: The Untold Story from Persecution to Vindication. He promises an exposé comparable to Harriet Beecher Stowe’s exposé of slavery in Uncle Tom’s Cabin. His thesis is that the AMA waged a shameless attack on competition, motivated only by money. I think the reality is closer to what he quoted from Dr. Thomas Ballantine, Harvard Medical School:

The confrontation between medicine and chiropractic is not a struggle between two professions. Rather it is more in the nature of an effort by an informed group of individuals to protect the public from fraudulent health claims and practices.

The book is self-published, long-winded, repetitive, and flawed. It is a vicious screed crammed with bias, half-truths, insulting language, and innumerable references to Nazis and racial prejudice. In my opinion, Smith not only fails to make his case but degrades chiropractic.

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Posted in: Book & movie reviews, Chiropractic, History

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Obamacare and CAM III: Great Expectations

In a previous post, we looked at how so-called “complementary and alternative medicine” (or “CAM”) might fit into the definition of “essential health benefits,” which must be covered by insurers pursuant to the Patient Protection and Affordable Care Act (“Obamacare,” or the “ACA”). In another, we contemplated what it might mean for insurers to “discriminate” against CAM providers, which is prohibited by the ACA. In both posts, the conclusion reached was that these provisions of Obamacare might not incorporate CAM practices into health care at the level CAM providers were hoping for. Here again we examine how the great expectations of CAM promoters may not be met in health care reform.

This time, we take a look at some additional provisions of the ACA that CAM lobbyists and their friends in Congress managed to insert into the healthcare overhaul. Of course, whether the ACA is around for much longer will depend on the outcome of the November elections, although Gov. Romney’s promise to “repeal Obamacare” if elected president will happen only if his party wins a majority in both the House of Representatives and Senate.  (more…)

Posted in: Acupuncture, Chiropractic, Legal, Naturopathy, Politics and Regulation

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Sports Physicals, Sudden Death, and Chiropractors

A correspondent sent me a link to an article about the decision of the Wichita Falls (Texas) Independent School District to recommend that chiropractors be allowed to give sports physicals to junior high and high school students. Current policy limits examiners to physicians, physician assistants, and nurse practitioners. Adding chiropractors to this list would bring the district in line with policies in the rest of Texas, as well as in some other states. And it would “give parents more options.”

I’ve written about the attempts of some chiropractors to assume the role of family doctors and why I think it is a terrible idea. The idea of allowing them to do sports physicals impresses me as somewhat less terrible, but not by very much.

The Reasons for Requiring Sports Physicals

The goals of the Pre-participation Athletic Exam (PAE) include:

  • To identify athletes who should not participate because of high risk of injury or death
  • To identify those who require further evaluation or treatment so they can participate safely
  • To identify conditions that do not affect athletic participation but that should be treated
  • To possibly identify those at risk for substance abuse, depression, violence, etc.
  • To provide preventive health advice
  • To satisfy legal requirements. (more…)

Posted in: Chiropractic, Public Health

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Don’t call CAM “cost-effective” unless it’s actually effective

Your health insurance plan probably covers anti-inflammatory drugs. But does it cover acupuncture treatments? Should it? Which health services deliver good value for money? Lest you think the debate is limited to the United States (which is an outlier when it comes to health spending), even countries with publicly-run healthcare systems are scrutinizing spending. Devoting dollars to one area (say, hospitals) is effectively a decision not to spend on something else, (perhaps public health programs). All systems, be they public or private, allocate funds in ways to spend money in the most efficient way possible. Thoughtful decisions require a consideration of both benefits and costs.

One of the consistent positions put forward by contributors to this blog is that all health interventions should be evaluated based on the same evidence standard. From this perspective, there is no distinct basket of products and services which are labelled “alternative”, “complementary” or more recently “integrative”. There are only treatments and interventions which have been evaluated to be effective, and those that have not. The idea that these two categories should both be considered valid approaches is a testament to promoters of complementary and alternative medicine (CAM), who, unable to meet the scientific standard, have argued (largely successfully) for different standards and special consideration — be it product regulation (e.g., supplements) or practitioner regulation.

Yet promoters of CAM seek the imprimatur of legitimacy conferred by the tools of science. And in an environment of economic restraint in health spending, they further recognize that showing economic value of CAM is important. Consequently they use the tools of economics to argue a perspective, rather than answer a question. And that’s the case with a recent paper I noticed was being touted by alternative medicine practitioners. Entitled, Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations, it attempts to summarize economic evaluations conducted on CAM treatments. Why a systematic review? One of the more effective tools for evaluating health outcomes, a systematic review seeks to analyze all published (and unpublished) information on a focused question, using a standardized, transparent approach to evidence analysis. When done well, systematic reviews can sift through thousands of clinical trials to answer focused questions in ways that are less biased than cherry-picking individual studies. The Cochrane Review’s systematic reviews form one of the more respected sources of objective information (with some caveats) on the efficacy of different health interventions. So there’s been interest in applying the techniques of systematic reviews to questions of economics, where both costs and effects must be measured. Economic evaluations at their core seek to measure the “bang for the buck” of different health interventions. The most accurate economic analyses are built into prospective clinical trials. These studies collect real-world costs and patient consequences, and then allow an accurate evaluation of value-for-money. These types of analyses are rare, however. Most economic evaluations involve modelling (a little to a lot) where health effects and related costs are estimated, to arrive at a calculation of value. Then there’s a discussion of whether that value calculation is “cost-effective”. It’s little wonder that many health professionals look suspiciously at economic analyses: the models are complicated and involve so many variables with subjective inputs that it can be difficult to sort out what the real effects are. Not surprisingly, most economic analyses suggest treatments are cost-effective. Before diving into the study, let’s consider the approach:

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Posted in: Acupuncture, Chiropractic, Energy Medicine, Herbs & Supplements, Homeopathy, Naturopathy, Science and Medicine

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Obamacare and CAM II: Discrimination (or not) against CAM

Supporters of science-based medicine have expressed concern over this provision in the Patient Protection and Affordable Care Act (“Obamacare,” or the “ACA.”):

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 from establishing varying reimbursement rates based on quality or performance measures.

Section 2706 (now codified as 42 U.S.C. Sec. 300gg-5) goes into effect in 2014 and covers virtually all individual and group insurance market policies, although it is not clear whether it will apply to existing policies “grandfathered” in 2010 by the ACA.

Section 2706 was not part of the U.S House of Representatives version of the ACA but was included in the Senate version (which ultimately passed) under the guidance of (surprise!) Sen. Tom Harkin (D-Iowa). It was heavily lobbied by the American Chiropractic Association and other “CAM” providers, as well as some “conventional” providers like nurse anesthetists and optometrists. The legislative history (reports, committee minutes, floor debates and the like which precede a vote on a bill) indicates it was specifically included to prevent discrimination against CAM providers.  This is of obvious concern to anyone who supports science-based, or for that matter evidence-based, medicine, as there is nothing to indicate that scientific plausibility or evidence (or the lack thereof) actually affects CAM practices. It should also concern insurers and those who pay for insurance (employers and individuals) to the extent it might require payment for CAM treatments, as ineffective treatments will negatively affect their bottom line. The U.S. Departments of Health and Human Services (HHS) and Labor and the Treasury Department, which are charged with issuing regulations implementing the ACA, have not yet promulgated regulations for Section 2706. The American Medical Association House of Delegates has already passed a resolution seeking its repeal.

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Posted in: Acupuncture, Chiropractic, Legal, Naturopathy, Politics and Regulation

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