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Chiropractic Education for Primary Care

Chiropractors would like to reinvent themselves as family doctors. I’ve written about that before and Jann Bellamy has written about it here, here, here, and here. A new study in The Journal of Chiropractic Education alleges that the National University of Health Sciences is nearing its institutional goal of training chiropractic students as primary care practitioners. The data they collected don’t even begin to support that assertion. The study is not only meaningless, it demonstrates a gross misunderstanding of the education required to practice competent primary care.

Traditional education of MDs

The 4 years of medical school are very different from those of a chiropractic school. When I was a student, the first two years were spent in classrooms and labs studying gross anatomy, physiology, pharmacology, pathology, biochemistry, histology, neuroanatomy, microbiology, immunology, embryology, and other meaty science subjects. In the 3rd year, students moved into the hospital wards, rotating through internal medicine, surgery, pediatrics, OB/GYN, psychiatry, neurology, radiology, emergency medicine, etc. 4th year clinical rotations involve a higher level of responsibility and include electives. Most of the clinical experience is with seriously ill hospitalized patients, but students also get some outpatient clinic experience.

The real training begins after graduation, when students get to put their learning into practice. They assume primary responsibility for patients, under supervision. I did what was called a “Rotating 0” internship, designed to provide a broad foundation before entering a specialty. I rotated through internal medicine, surgery, OB/GYN, pediatrics, and electives (neurology and ENT). Most of my time was spent on the hospital wards, but I also worked in outpatient clinics and in the ER. The experience was intensive, with call every 3rd night. This meant working all day, all night, and the following day for a total of 32+ hours straight, followed by a day when we worked 9-10 hours and got to go home in the evening. In my case, my training was interrupted by an Air Force assignment as a General Medical Officer, and after that I spent 2 years in a 3-year residency in Family Practice (my internship counted for year 1). Residencies are where doctors get their training in a specialty, with graduated responsibilities as the program proceeds. At 3 years, the family practice residency is one of the shortest; a surgery residency typically lasts 5 years, a neurosurgery residency 7 years. In some cases, a residency is followed by a fellowship in a subspecialty, such as gastroenterology or child psychiatry. Rigorous exams are required at various stages of training and for board certification in a specialty.

Changes in recent years

Since I graduated, there have been new developments. There are limits to the number of consecutive hours a resident can work; medical schools are integrating classroom training with clinical experiences in various ways; there is a new designation of “hospitalists” who care for inpatients admitted by other doctors. Some primary care and even some specialty care is carried out by nurse clinicians and physician assistants with lesser levels of training than MDs, training more focused on what they will actually be doing in practice. PA training typically involves 2-3 years of postgraduate study, and most PA students have previous health care experience.

Chiropractic education

Chiropractic education is much less rigorous. Class time is taken up by many hours of training in manipulation technique like “toggle,” and “cervical technique,” palpation, and “subluxation” analysis; and for subjects like financial management and practice management. They don’t get any experience caring for seriously ill hospitalized patients. There is no internship or residency. The NUHS calls students in its student clinic “interns,” but that bears no resemblance to what “intern” means in medical training. The training it offers is in line with the purpose of the Council on Chiropractic Education, and they state “students at NUHS are educated and clinically trained to become primary care physicians. To become an effective primary care provider, a student intern must be prepared to identify, manage, and refer successfully when necessary a broad scope of conditions that include musculoskeletal and nonmusculoskeletal problems.”

The NHUS study

The study’s purpose was to quantify the number of musculoskeletal and nonmusculoskeletal cases NUHS interns treat during the clinic component of their education and to compare the results to data available for chiropractic and “allopathic” providers. The method was a retrospective chart review based on diagnostic codes. Of a potential 173 patients scheduled to be seen in the specified time frame (one trimester), 8 were no-shows, 27 denied consent, and 25 patients had no treated diagnoses, leaving only 113 patient files to be analyzed.

The results: 297 coded diagnoses, 76% of these musculoskeletal. Treated diagnoses: 52.2% musculoskeletal only, 12.4% nonmusculoskeletal only, and 35.4% both musculoskeletal and nonmusculoskeletal. This compared to 83% musculoskeletal and 17% nonmusculoskeletal diagnoses for practicing chiropractors, and 10% musculoskeletal and 90% nonmusculoskeletal diagnoses for “allopaths.”

Diagnoses not represented: neoplasms, blood disorders, diseases of the circulatory system, complications of pregnancy, childbirth and puerperium, and perinatal conditions. Out of 113 patients, only one was under the age of 20, and none were under the age of 11. Here is the list of diagnostic categories:

chiropractic article

Note that the list of categories includes only 1 infection, 2 endocrine, nutritional and metabolic diseases, 4 diseases of the respiratory system, 4 diseases of the respiratory system, 3 diseases of the genitourinary system, 2 diseases of the skin, and there are several categories with no patients at all. These are just categories, they don’t tell us the actual diagnoses, whether they amounted to what has been called “snotology” (minor complaints like colds) or more serious disorders.

They don’t say how many students were involved, but elsewhere I found that 84 students are enrolled in the program. Surely no one student could have seen more than a few patients or seen a full spectrum of these diagnoses.

The authors point out another serious problem: diagnoses like hypertension or diabetes mellitus were not treated by students, but were “monitored or appropriately referred.”

Comparison to primary care

Contrast that to the 25 most common diagnoses seen in primary care: hypertension, hyperlipidemia, and diabetes lead the list, followed by back pain, anxiety, obesity, allergic rhinitis, reflux esophagitis, respiratory problems, hypothyroidism, visual refractive errors, osteoarthritis, fibromyalgia/myositis/neuritis, malaise and fatigue, joint pain, acute laryngopharyngitis, acute maxillary sinusitis, major depressive disorder, acute bronchitis, and asthma.

The chiropractic students all put together saw a total of only 2 patients who fell into one of the categories of the top 3 conditions presenting to primary care providers. As defined by the CCE, primary health care is:

Care that is provided by a health care professional in the patient’s first contact within a health care system that includes an examination and evaluation, diagnosis and health management. A Doctor of Chiropractic practicing primary health care is competent and qualified to provide independent, quality, patient-focused health care to individuals of all ages and genders by: (1) providing direct access, portal of entry care that does not require a referral from another source; (2) establishing a partnership relationship with continuity of care for each individual patient; (3) evaluating a patient and independently establishing a diagnosis or diagnoses; (4) managing the patients [sic] health care and integrating health care services including treatment, recommendations for self-care, referral and/or co-management.

Conclusion

How could anyone possibly imagine that the findings of this study show that the school is approaching the goal of “training students to become primary health care providers”? You would have to be delusional to think that. They saw no children and no patients with the top 3 conditions presenting to a primary care office. The numbers tabulated were for the entire group of students, with no indication of the numbers seen by any individual student.

It’s just plain stupid to think that simply listing diagnostic categories could establish the adequacy of training.

Apart from the inadequacies of clinic training, there is a glaring defect: chiropractors don’t have inpatient hospital experience with responsibility for the care of seriously ill patients. Without that experience, how could they be expected to develop good judgment about when to refer and when hospitalization is necessary?

Chiropractors are not qualified to provide primary care. This study only reinforces that fact.

Posted in: Chiropractic

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146 thoughts on “Chiropractic Education for Primary Care

  1. Calli Arcale says:

    Care that is provided by a health care professional in the patient’s first contact within a health care system that includes an examination and evaluation, diagnosis and health management.

    That last part is a real sticking point that the chiropractic schools try to distract attention away from. In order to obtain some degree of respect as a PCP, they have to be able to take credit for handling anything that gets presented to them. Since they obviously are not in a position to treat* bladder infections, acid reflux disease, cancer, meningitis, or massive trauma, they instead point out how well they can recognize these things and refer appropriately.

    This is a distraction technique, of course, because a PCP should be able to do more than just refer appropriately. To be able to *manage* the patient’s care, they need to be at least minimally competent in treating the patient’s condition. A chiropractor cannot treat acid reflux disease; at best, they can give advice about weight loss, which will only help some of the time. (My beanpole of a daughter has acid reflux disease, managed with Zantac. Losing weight would be a very bad thing in her case.) And by presenting “oh, we can refer you” as a solution, they run the very real risk of delaying treatment. Somebody with chest pain who sees the chiropractor may suffer needless damage to their heart because of the delay in getting properly diagnosed and treated. Somebody with neck pain and headache with fever may be referred to an ER if the chiro is alert enough to recognize symptoms of meningitis, but that delay could be very costly.

    *They think they can treat these things, of course, but they know that insurers and many of the public are at least well enough informed to know that they can’t, so they have to find a way of assuaging the well-justified fears of those who stand between them and widespread acceptance as PCPs.

    1. krsplsh says:

      so EVERY PCP treats “bladder infections, acid reflux disease, cancer, meningitis, or massive trauma” directly in their office? i can understand bladder infection (with antibiotics) and GERD (with “the purple pill”) but cancer? meningitis? or massive trauma? i believe that specialist in whatever organ/tissue or issue will be referred out for those patients from a general practice doc.
      as for chiropractors from numerous institutions being good health care providers, i dont think so. some are, and some aren’t (just like in medicine). i am a chiropractor and my profession is filled with quacks, idiots and absolute frauds. but, there are a few good ones that actually care for the patients, dont use the word “subluxation” (of which there are a number of chiropractors that abhor such word, as do I) and refer out when a non musculo-skeletal problem arises.
      i agree with many of you on here that shudder when a chiropractor treats an organ by “removing interference with a nerve from the spine”! it disgusts me that such practices are done. but, like all professions, there are good ones and then there are the ones everyone wishes would go away (“bad apple spoils it for all” comes to mind)!
      I have seen numerous patients that came to me for whatever condition and I noticed something didn’t add up so I referred them out. every single one of them were thankful that I caught what their GP didnt catch and in some cases actually saved their life (from arterial blockage,CHF, cancer, etc). I know i can’t fix all issues, but it is good practice to work with all health care providers for the patients sake/health.
      where i went to chiropractic school, we invite the (and i believe they have to do it) local medical school students to come in for a week to see what we learn(ed), what we are taught and learn what the complementary health care providers do/learn (this is Chinese medicine, massage and chiroprctic). many of the MD students leave with a completely different way of looking at what the school teaches it’s students and walk away astounded at the completeness of education we have at our disposal, compared to medical school. it also taught us that MD students can be opened to what we learned, but we should also be open to what they learn as well. many of my classmates, and myself included, left with a much more conclusive treatment of patients when it comes down to care for a potential patient. each brings something to the table and each profession has it’s strengths and each has weaknesses.
      the only negative i have about many MDs is that they all think that pharmaceutical medication is the only answer to treating a disease or problem. this is not the case in some instances. I do not believe that all fixes of health are in medicine.

      1. WilliamLawrenceUtridge says:

        Why aren’t you a physiotherapist? Particularly since SMT is now being taught as part of the regular physio curriculum.

        And it sounds like you agree that chiropractors shouldn’t be PCP, you should at best be a specialist in mechanical muscle and joint problems; such specialists are not PCP, they are referred to by PCP.

        And unlike PCPs/MDs/DOs whose education is primarily science-based and it is the rare quack who goes crazy for unscientific CAM, a fundamental division and group of chiropractors are quacks from the get-go, with quackery being a fundamental part of their education and paradigm. Even if you are a science-based, muscle-and-joint focused practitioner, other people with the exact same designation and title as you have crazy and unscientific beliefs about their capabilities. How does that make you feel as a chiropractor? How should patients tell the two branches apart? Shouldn’t the science-based chiropractors such as yourself take a stance and separate yourself from the nutters rather than apologizing for them? Osteopaths became science-based and essentially merged with MDs, why not do the same with physiotherapy?

        If you are so science-based, why do you do things like traditional Chinese medicine, which is based on prescientific dogma?

        The idea that MDs only treat with drugs is a fallacy and inaccuracy that you are spoon-fed during your education, a nice little bit of rhetoric that your profession collectively uses to belittle competitors and enrich your own practices. It would do you credit to abandon it.

        I believe that all fixes in health are found in medicine, because once an intervention, be it a drug or mechanical manipulation or lifestyle modification is proven to improve health, it is adopted and taught as part of mainstream medicine. Perhaps think about that the next time you are criticizing doctors; all they ask for is proof, because your word alone simply isn’t enough.

      2. windriven says:

        I’d like to know what it is that chiropractic brings to the table of medical care. What is it that you think you do better than physicians and physical therapists?

  2. tgobbi says:

    Dr Hall states: “National University of Health Sciences is nearing its institutional goal of training chiropractic students as primary care practitioners.”

    That would be amusing if it weren’t so scary! A glance at their website shows that they’re totally devoted to a quack agenda: they offer programs in chiropractic; naturopathic “medicine;” acupuncture; oriental medicine; and biomedical science. I have no idea what that last one is, but based on the other four, I wouldn’t be surprised to discover that it, too, is blatant quackery.

  3. Carl says:

    Is there any comparison of outcomes? It sounds like the study is just using the fact of the act of treatment as if it were evidence that training was adequate. If I crash into the OR with my Kabar and a flashlight and start hacking at some guy with a brain tumor, does that mean I am qualified to treat brain tumors?

    But it doesn’t really even break it down by specific treatment. It basically amounts to saying the student must be qualified because the patient came to them with the complaint.

  4. Spencer Septién says:

    Forgotten again the lowly DO. Just wait until the Naturopaths and Acupuncturists make their push for primary care / family doctor distinction.

    1. Brad Smith says:

      Yep. Check out this acupuncture clinic based in Brisbane, Australia:

      http://www.tlcacupuncture.com.au/

      These guys want people to stop seeking cancer treatment at hospitals and simply get acupuncture from them instead.

      1. WilliamLawrenceUtridge says:

        C’mon Brad, how will acupuncturists make money if patients keep going to hospitals instead of acupuncturists?

        THINK OF THE MONEY!!1!!1!!

  5. RobRN says:

    “National University of Health Sciences”? How do they get away with using “Health Sciences” in their name when all they teach is WOO? It’s a blatant and shameless attempt to gain undeserved credibility.

  6. Kathy says:

    “The method was a retrospective chart review based on diagnostic codes”.

    I’m a little confused here … does that mean that the patients were assigned to the different categories on that table according to the diagnosis by a student? Did their lecturers check if they got them right (assuming the lecturers know any better than the students)? One fairly jumped out at me: Mental disorders vs Diseases of the nervous system … would a student know how to tell these apart?

    Mind you, “Symptoms, signs and ill-defined conditions” seems like a popular garbage can and is far the biggest category. That should cover all bases {sarcasm}.

  7. Windriven says:

    It seems to me that, regardless of what they might say, the federal government will not be displeased to see a variety of quacks, poseurs and wannabees serving as primary care physicians. ACA endeavors to bring perhaps 30 million newly insured into the mainline health care system. Yet federal funding of the medical residency program has remained largely frozen for the last decade. Further, some argue that Residency Review Committees work to limit the number of residents admitted (to keep supply tight and reimbursement high), thereby exacerbating the problem.

    In any event the imperatives of supply and demand will shape the outcome. People are not going to spend a large chunk of money every month on insurance for the privilege of waiting till next never to see a physician. Some will choose quacks because they buy into the quackery. Some will choose quacks because they can’t get a timely appointment with a physician and will figure that the quacks have the government stamp of approval so how bad can they be.

  8. Luara says:

    A comparison to the training of nurse practitioners is perhaps more fair, because they also do primary care.

    1. WilliamLawrenceUtridge says:

      That seems as much an insulting comparison to nurse practitioners as it does to doctors.

    2. Luara says:

      My point is, that a more fair comparison is of chiropractors with the least highly trained people who currently do primary care. Nurse practitioners are less highly trained than doctors but are often considered to be capable of doing primary care by themselves. The chiropractors should at least be able to diagnose and treat as well as a NP.
      Chiropractors are people too :) and it’s no insult to compare them to other people like doctors or NP’s.

    3. Luara says:

      PS Nurse practitioners are allowed to set up practices on their own in some states – so they are considered qualified to know when a patient should be seen by a doctor.

      1. WilliamLawrenceUtridge says:

        I still see it as an insult to Nurse Practitioners. NPs are reality-based, who have to spend a lot of time learning about genuine patient care using a wide variety of modalities to assess and treat, looking at the whole person.

        Chiropractors see a spine and a wallet.

        If I were an NP, I would be offended.

        I can see your point, that chiropractors are attempting to attain a standard of care perhaps best compared to someone less trained than a doctor, but I still don’t think it’s apt. Perhaps comparing them to NPs is more “fair” or reasonable as it is a lower standard of care – but I would still say if they want to be NPs, if they want to be PCP, they should train as such, not as chiropractors. A better comparison in my mind would be physiotherapists, whom I don’t think should be PCP (and neither do physios for that matter).

      2. Exley says:

        As a recent user of a good chiropractor:
        Medicine per se has never really helped my bad back. As an old 88 year old my back frequently must have the lower vertebra put back in place and other parts of the back that is now hurting also because I waited to long to go. Medical Doctors with MRI’S DO NOT RECOGNIZE the PROBLEM AND IMMEDIATELY give you back shots for pain management. The chiropractor I use seems to know all the muscles, bones, nerve associations and all the stuff masseurs know -the kind of care primary providers fail to send you to as you wait for two weeks to see an appropriate medical doctor.
        My father-in-law was sent to a medical doctor by his chiropractor for a stent in his neck – having never been recognized before. Some medical doctors fully recognize the value that chiropractor can be to the medical community, where some give all chiropractors a “thumbs down” when the word is mentioned. They should work together – particularity since the HMO’s have moved away from the old home stile doctor.

        1. WilliamLawrenceUtridge says:

          The one thing chiropractors bring to health care is experience with back pain – realistically the only thing they could bring since all they do is adjust the back (unless they’re selling vitamins or giving medical advice). They’re just redundant to physiotherapists, particularly since the latter is bringing spinal manipulation into their practices now that it has been scientifically validated as a reasonable treatment for back pain.

        2. Harriet Hall says:

          I’m glad manipulation is helping your back, but whatever the chiropractor is doing, he is NOT putting a vertebra back in place. If a vertebra were out of place, it would show up on x-ray. Chiropractic “subluxations” are not demonstrable on x-ray.
          When a vertebra is truly out of place it is almost always due to fractures or other severe trauma, severe arthritis, or spondylolisthesis. And spinal manipulation therapy is not indicated for any of those.

          1. Cody Scharf says:

            X-rays are an unrealistic tool of subluxation diagnosis. Muscle spasm, accompanying most acute pain symptoms, leads to those misalignment found on film by chiropractors. After the pain settles, you would be able to see the return of proper alignment, even without treatment in most cases.

            1. WilliamLawrenceUtridge says:

              Why are X-rays unrealistic but muscle spasms are? Has your hypothesis been tested? Has anyone shown that multiple chiropractors, given the same symptoms of acute pain and muscle spasm, agree which vertebrae are out of alignment, then go on to agree on a treatment plan which resolves their customer’s symptoms faster than usual care?

              Without evidence, it’s just your opinion. Why don’t you get some evidence?

  9. Donna B. says:

    If I was getting paid for what I do, I’d call myself a “lay patient coordinator” or something similar. What I do is keep track of my father’s and my husband’s various ailments and physicians. My father is 90 and my husband is 73. Between them, I’ve had to learn (in layman’s terms) about normal pressure hydrocephalus, bladder cancer, prostate cancer, lung cancer, colon cancer, COPD, congestive heart failure, stenting for cardiac blockages, arthritis, low/high blood pressure,

    Thank goodness they both have very very good PCPs.

    And through a dozen or more hospitalizations with both of them, I give kudos to hospitalists for taking good care of them during that time… BUT, there have been several occasions when the hospitalists have changed medications without consulting with the patient’s PCP or the various and numerous specialists that are treating them. A recent example is changing a Zantac prescription to omeprazole when the patient was doing well with the Zantac and digestive issues were not the reason for the hospitalization or a concern during hospitalization.

    More disturbing was a hospitalist’s discontinuing of ALL cardiac medications when the patient was hospitalized because of low blood pressure. It didn’t bother me so much that those medications were discontinued during the hospitalization where monitoring was continuous, but the discharge instructions also stated that all of them were to be discontinued and did not include instructions to follow up with a cardiologist.

    Over the years, I’ve learned to schedule an appointment with the PCP as soon as possible after a hospitalization. This practice has not backfired on me yet. The PCPs taking care of my husband and father have been involved in their care for > 10 years and can and do look at the “whole person”. This means they make referrals to specialists when they need to. It also means they arbitrate, negotiate, and coordinate when there are conflicting treatment options. This occurs most frequently when heart medications also lower blood pressure. It’s a fine line there.

    Throw into this mix of PCPs, specialists, and hospitalists… the VA. Both my husband and father are disabled vets (80% and 100%) and this means that there’s another PCP. This VA PCP controls prescription cost (more so for my father than for my husband who is also a military retiree and can use Tricare for most prescriptions).

    I shudder to think what kind of mess I’d find myself in if either of my *patients* were to have a chiropractor as a PCP.

    My father is more prone to treatments by chiropractors than is my husband. My father has also been known to like what he calls “witch doctors” who do aromatherapy and reiki… even though he says he knows they are quacks, he likes the attention. I succeeded in weaning my father from chiropractors when I explained the “good” business practice of offering a “discount” if a year’s worth of treatments were paid in advance. He’s woo-susceptible, but he’s not stupid where his bank account is concerned.

    What scares me is that both the PCPs I rely on to care for my husband and father are near retirement age. I’m nearing the designation elderly myself and while I like my current PCP (a PA in a military setting) I don’t think I’ll ever have the continuity of care that my father and husband have had. I fear that they (especially my husband) are in danger of losing it too.

    I fear that a general lack of generalists (PCPs) is going to make it too convenient for chiropractors and other wooists to fill the void. Please understand that I fully appreciate the knowledge of medical specialists — but I think that their focus sometimes lends strength to the claims of woo purveyors that they don’t consider the “whole” person.

    1. agitato says:

      Donna B said:
      “I shudder to think what kind of mess I’d find myself in if either of my *patients* were to have a chiropractor as a PCP.”

      I agree. But I also shudder to think what kind of mess your *patients* would be in without YOU there to coordinate and advocate on their behalf. I think everyone discharged home from hospital without an advocate like you should be contacted by a visiting nurse ASAP for all of the reasons you have just outlined. And I think you should somehow be compensated for the hours of unpaid work you’re doing to make the very complicated health care system of today work.

  10. Chris Hickie says:

    Here’s a lovely pair of chiroquackers: http://www.godiscoverhealth.com/

    According to these two, God made us well enough to *only* need chiropractic care (how convenient for their business!). They especially like to prey on children in their “clinic”. Even worse, they have this book coming out: http://www.russell-media.com/books/baby-designed-by-god-single-book/baby-designed-by-god

    If scam artists like these two get PCP status, I think I will go find another career, because I’m pretty sure the same dolts in government who might elevate these charlatans to the level of PCP would also enact some sort of rule that MDs can criticize these dopes.

    1. Carl says:

      @Chris Hickie…

      I think the British already have some “ethics” rule which says doctors should behave like opinionless servants to the government. I suppose the quacks here might sneak the same thing into a bill.

      1. Chris Hickie` says:

        That must be why Doc Martin is so brusque to his patients, since he has nowhere else to vent!

  11. Chris says:

    I just saw a good cartoon for Dr. Hall to add to the presentation she gave this evening:
    http://www.gocomics.com/lola/2013/10/16

    I know it is off topic, but apparently there are online schools for naturopathy.

    1. goodnightirene says:

      Love the cartoon! Thanks.

  12. pmoran says:

    While naturopaths and other CAM practitioners may now be catching up, chiropractors have always had an exceptionally inflated perception of the adequacy of their education and their ability as PCPs. Medicine looks very easy to those who have little final responsibility for patients, because others are doing all the “heavy lifting” ( a borrowed but very apt phrase).

    This seeming obliviousness to their own limitations is one of the most worrying aspects, should chiropractors be given PCP status. It is bound to get many of them into trouble. They will be out to prove competency when they should be referring on. When will they have ever acquired the skills to asses someone with abdominal pain, for example?

    Another historical tendency within the chiropractic mind is its embattlement with, and antipathy towards the mainstream. It is difficult to imagine chiropractors not acquiring some of this during their development, which makes one doubt that they will ever develop the close working relationships with colleagues and specialists that are such an essential feature of safe and effective primary medical care. They may get around this by off-loading a lot of cases onto hospital emergency departments but that will adversely affect their efficiency.

    But the worst aspect is that even well-trained doctors can make serious mistakes. There is no good case for allowing less well trained persons to take over their duties. A well-supervised practice nurse would be a better solution to any scarcity of PCPs. They can take over many routine duties.

    1. William says:

      Do really think chiropractors would be ” given” PCP status.
      And your comment ” when will they ever have acquired the skills to be able to evaluate abdominal pain”
      Do you mean skills or experience?
      As I read on I wonder what planet you are from.

  13. Windriven says:

    “But the worst aspect is that even well-trained doctors can make serious mistakes. There is no good case for allowing less well trained persons to take over their duties. A well-supervised practice nurse would be a better solution to any scarcity of PCPs. They can take over many routine duties.”

    Some of this is happening in the US – though too little in my opinion. Further, at least in the US, PCPs often lag far behind the compensation earned by other physicians. PCPs are the ‘tip of the spear’ and should, in my opinion, be rather well compensated vis-a-vis their peers in other specialties.

  14. Salty Dog says:

    The issue of lack of exposure during training to the wide variety of conditions seen in a primary practice is very important, but the focus of our attention needs to be on their methods of diagnosis and treatment. This will most certainly be based on “subluxations” and have no science base. That is the fatal and obvious flaw in their proposal and needs to be emphasized to the public at every opportunity.

  15. Greg says:

    Only a fool would consider a Chiropractor a primary care physician…

  16. MTDoc says:

    Harriet, your description of traditional medical education sure brought back memories! Our careers have many similarities, except I’m a decade older, and did my residency after leaving the USAF (only six years). My residency was also different in that it included lots more surgery and OB, so that primary care for me was far different than what it is now. For example, when I came to my little valley in Montana, there were no orthopedic surgeons here. And now there are 20 or so, and the population has not quite doubled. We did all our own hospital work and even saw our patients when they were under a specialists care, unpaid, I might add. My point is that “primary care” has become little more than triage. Not a career choice I would make today.

    1. windriven says:

      MTDoc,

      You say that primary care has become little more than triage. But hasn’t the breadth and depth of medical knowledge grown to proportions that a single practitioner can’t possibly be genuinely competent in more than a few areas?

      I don’t suggest this as in anyway demeaning of PCPs. Quite the contrary, PCPs necessarily must command a breathtaking array of medical knowledge and must make decisions quickly and surely. All while as a sideline, running the business which is his or her practice.

      Sounds both demanding and rewarding – though unfortunately not so much in financial terms.

      1. MTDoc says:

        You are probably correct. I am probably still living in the previous century. Still we managed the vast majority of patient care, saw everyone who needed urgent care the same day, took ambulance and night call, and did this with a fraction of the number of physicians we have today. The demands today have more to do with finding codes for everything, and complying with ever changing regulations, than with managing the patient’s problem. My wife, an RN, still works for my “old clinic” and spends more time on the phone or eletronically recording medical records than interacting with patients. I guess I just miss the old days when we spent more time with our patients and we were both happier.

        1. MTDoc says:

          An axiom in primary care: You need to know all that stuff (medicine IS complicated) , and have all that training so that you know what you don’t know. Of course, you also have to have the common sense to recognize it.

  17. lizditz says:

    Today from Edzard Ernst:

    ….a guest post by Preston H. Long. It is an excerpt from his new book entitled ‘Chiropractic Abuse—A Chiropractor’s Lament’. Preston H. Long is a licensed chiropractor from Arizona. His professional career has spanned nearly 30 years. In addition to treating patients, he has testified at about 200 trials, performed more than 10,000 chiropractic case evaluations, and served as a consultant to several law enforcement agencies. He is also an associate professor at Bryan University, where he teaches in the master’s program in applied health informatics. His new book is one of the very few that provides an inside criticism of chiropractic. It is well worth reading, in my view.

    Long on chiropractic training:

    3. Our education is vastly inferior to that of medical doctors.
    I rarely encountered sick patients in my school clinic. Most of my “patients” were friends, students, and an occasional person who presented to the student clinic for inexpensive chiropractic care. Most had nothing really wrong with them. In order to graduate, chiropractic college students are required to treat a minimum number of people. To reach their number, some resort to paying people (including prostitutes) to visit them at the college’s clinic.
    Students also encounter a very narrow range of conditions, most related to aches and pains. Real medical education involves contact with thousands of patients with a wide variety of problems, including many severe enough to require hospitalization. Most chiropractic students see patients during two clinical years in chiropractic college. Medical students also average two clinical years, but they see many more patients and nearly all medical doctors have an additional three to five years of specialty training before they enter practice.

    There’s more. Go read the post and buy the book.

    1. Harriet Hall says:

      Stay tuned. I’ve written a book review that will be posted Tuesday after next.

    2. Wiliam says:

      what chiropractors are claiming that they get more experience than medical students?
      None
      The author says
      Chiropractic education is much less rigorous. Class time is taken up by many hours of training in manipulation technique like “toggle,” and “cervical technique,” palpation, and “subluxation” analysis; and for subjects like financial management and practice management.
      Show us where you got that information,especially since your “well researched” article was about a study from NUHS. researchers.

      1. Harriet Hall says:

        Did anyone say chiropractors are claiming that they get more experience than medical students? They clearly don’t. The point is that they are claiming competence as primary care providers with hardly any experience at all.

        “Show us where you got that information”
        If you are talking about the information on the use of class time, I consulted the curriculum of Palmer College of Chiropractic, one of the top rated schools, at http://www.palmer.edu/uploadedFiles/Pages/Marketing/Publications/Official_College_Documents/Sample_Curriculum/Davenport_Campus_Sample_Schedule_brand.pdf

        1. Wiliam says:

          Good one! You know well that there are different factions in chiropractic.
          You choose the original ” straight” school and compare them to NUHS who have long been considered mixers and essentially at odds with Palmer.

          And any group can say they want to do this or do that but a state board and other legislative bodies have to allow that. You know DCs are along way off from that if ever. Not that many DCs are interested in being true PCPs even if they could. How likely
          is an insurance company to reimburse DCs for even blood work let alone to manage someone’s HTN or hyperlipidemia with “natural” means.
          No need to further insult those reasonable DCs and rile the SBM minions.

          1. Harriet Hall says:

            I didn’t cite the NUHS curriculum, but here it is: http://www.nuhs.edu/academics/college-of-professional-studies/chiropractic-medicine/curriculum/course-descriptions/

            It includes these courses:
            Intro to Business Principles
            Principles of Marketing and Communication
            Business Planning
            Ethical Management of the Chiropractic Practice
            Jurisprudence and Ethics

            And their naturopathic curriculum contains extensive required coursework in homeopathy. NUHS specializes in CAM: TCM, acupuncture, homeopathy, chiropractic, naturopathy, massage. It doesn’t teach conventional medicine.

            For what it’s worth, a student at NUHS wrote “if you want to be a MSK doc, that practices Chiropractic DO NOT COME HERE. I am in my 7th trimester, and I don’t know how to properly diagnose back pain, have no clue about treatment, and don’t feel comfortable with my adjusting at all.”

            I find it interesting that the ratings for Palmer and NUHS are the same, and that neither school mentions whether its approach is that of “straights” or “mixers.”

            I truly hope you are right when you say chiropractors are a long way off from primary care, but NUHS specifically says that is its goal, and there are ominous signs in the political arena. I am not so sanguine.

          2. WilliamLawrenceUtridge says:

            Notice there’s not really “factions” within medicine, because it is based on empirical research. There are differences of opinions in the treatment of conditions when the evidence is equivocal, but eventually best practices are delineated and adopted.

            Mixers are again, at best, physiotherapists. Straights are flat-out crazy. Neither should be primary care physicians.

            How likely is an insurance company to reimburse DCs for even blood work let alone to manage someone’s HTN or hyperlipidemia with “natural” means.

            And thank the FSM for that since chiropractors aren’t trained or experienced to safely take, let alone analyze blood, let alone try to treat hyperlipidemia. And if those “natural” means are scientifically proven, then doctors would use them as well – making your profession redundant to real medicine, or unethical as you treat your customers without any proof that what you are doing is safe, effective and cost effective.

            No need to further insult those reasonable DCs and rile the SBM minions.

            I find it bizarre that you would take this stance while defending chiropractors. If you’re one of the “reasonable” ones, shouldn’t you be shouting from the rooftops that your peers shouldn’t be doctors? Aren’t you concerned about other chiropractors that claim to be able to treat and cure cancer, who tell their victims they should stop taking chemotherapy?

            Why didn’t you just become a physiotherapist?

      2. WilliamLawrenceUtridge says:

        what chiropractors are claiming that they get more experience than medical students? None

        And somehow that’s a feature, not a bug?

        Chiropractors learn primarily about musculoskeletal issues, and straights staple on to that a whole bunch of wrong beliefs about somehow being able to heal organs through spinal manipulation. They do not have the background information to be primary care physicians, nor do they have the experience. They barely have the experience to be a sort of second-rate physiotherapist, and the practice is accompanied by pernicious practices like “maintenance treatment” that lasts your whole life, expensive supplements, opposition to vaccination and scaremongering regarding real medicine.

        At best, you’re a physiotherapist. At worst, you’re an outright hazard.

      3. lizditz says:

        Claims that chiropractic education is superior to medical education? Dead easy to find, for example (emphasis added): MD vs. DC

        The Parker College study reported that on average, chiropractic college involves 372 more classroom hours than medical school. Chiropractic students also have more hours of training in anatomy, physiology, diagnosis, and orthopedics (the musculoskeletal system).

        It should be apparent from looking at the data below that in general, the chiropractic student has a more extensive classroom education and practical training in these areas, particularly in diagnosis, than the medical student.

        Does it surprise you that it is a website maintained by a chiropractor? One who claims to practice “functional medicine”?

        1. krsplsh says:

          so, it is maintained by a chiropractor, is there one that an MD has done? if so pull it up and compare. if not, research it yourself and see if he is accurate. if it is accurate, then it is what it is.

          1. windriven says:

            So now we’re going to compare competing websites, both of which might well be bullrip? Brilliant.

            Again I’d like to ask: what does chiropractic bring to the table? What are, say, the ten most important disease entities that chiropractic has eliminated or mastered? We can compare that to medicine’s contributions. No web sites. No sorta kindas. Just a straight up head to head comparison.

            1. windriven says:

              I wonder why whenever I ask this of a chiro or a naturopath I never get an answer? I guess with the huge inventory of contributions of their sCAMs to the human condition it is impossible for them to pick just 10.

        2. WilliamLawrenceUtridge says:

          In all of these discussions, we have to remember that there are at least two types of chiropractors. Straights are crazy, they think they can cure cancer. Mixers, of which krsplsh is one, are simply physiotherapists with a twist (of the spine).

          So the questions we should be asking krsplsh should not be “what diseases have you cured”, it should be “how are you different from physiotherapists?” Krsplsh doesn’t think he can cure cancer, or asthma, or allergies, or AIDS. He thinks he presents a unique set of skills to address musculoskeletal complaints. I’m trying to suss out what that set of skills is.

          1. windriven says:

            That’s fine. The question can be sliced and diced in a bunch of ways. The bottom line is: what do they bring to the table? However I ask that question I never get a meaningful answer. I usually get no answer at all.

  18. William says:

    There is nothing wrong with taking some business classes. It’s not like chiropractors
    have any of the instant job opportunities of medical doctors. Those classes are not the same as the Practice management groups

    Here’s a seven-year study, that ends by saying more research is needed.
    I believe you dismissed the original one done by AMI/NUHS.

    http://www.nmchiro.org/Original/journal0801/Sarnat_CAM_PCP_May07.pdf

    You also dismissed the Masters degree in advanced clinical practice that NUHS offers.

    So the fresh grad is unlikely to be your PCP anytime soon at least in your sense of what a PCP is.

    1. WilliamLawrenceUtridge says:

      Do you know what happens when a study concludes “more research” in real medicine? More research. Treatments don’t get implemented outside clinical trials, except by unethical douchebags like Burzynski.

      Has more research been done since that paper was published in 2007? In most of medicine, anything older than 5 years isn’t “cutting edge”, it’s borderline obsolete.

      Put more bluntly, you’re undercutting your own point by citing an old study that had equivocal results as a justification for current practice.

  19. James Winterstein says:

    It is interesting to hear the arrogant comments of those opposed to chiropractic medicine, especially when they have not attended a chiropractic program. Those allopaths who denigrate the idea of chiropractic physicians functioning as primary care providers very likely have little or no idea how primary care chiropractic physicians actually practice.

    A classic example of allopathic ignorance about chiropractic practice is characterized by the following comment ( A chiropractor cannot treat acid reflux disease; at best, they can give advice about weight loss, which will only help some of the time. (My beanpole of a daughter has acid reflux disease, managed with Zantac. Losing weight would be a very bad thing in her case.) And by presenting “oh, we can refer you” as a solution, they run the very real risk of delaying treatment.) by Calli Arcale above. Perhaps it would be useful to review the following because this exactly how many chiropractic physicians would treat GERD.

    (http://www.proteinpower.com/drmike/gerdacid-reflux/gerd-treatment-nutrition-vs-drugs-3/) – by Michael Eades, MD – oops perhaps he went to chiropractic school or is he simply aware of a therapeutic method that does not first involve the use of prescription drugs.

    My point is that this entire article is simply an attempt to denigrate a legitimate, accredited, legally recognized institution that provides extensive education leading to primary care by chiropractic graduates. Does this mean that every PCP treats every patient? Of course not. In fact, many (most?) PCPs who practice allopathy evaluate and manage at a primarily ambulatory level and then refer to specialists and or hospitalists when tertiary care is required. Has the allopath had more extensive training in the care of hospital patients? No doubt, but is that essential for the average PCP who sees patients in the office, arrives at a diagnosis and treats those patients for whom appropriate care is useful or refers to the specialist when necessary? Having practiced in a shared office with an allopathic primary care physician for 13 years, I found that while he did treat some more acute conditions, I often had much better choices of care for chronic patients. Instead of denigrating each other, however, we worked together for the benefit of our patients – isn’t that what we are supposed to be doing?

    We don’t need a cadre of allopaths writing negative articles about chiropractic medicine (that sounds an awful lot like turfism). If chiropractic education and care is so terrible, I think the courts and the chiropractic patients will made the decisions necessary. Strangely, chiropractic medicine has been around for 118 years, and National University has been functioning for 107 of those years.

    1. Harriet Hall says:

      “this entire article is simply an attempt to denigrate a legitimate, accredited, legally recognized institution that provides extensive education leading to primary care by chiropractic graduates.”

      No, the entire article is an attempt to refute the claim that that study shows evidence that chiropractors are being adequately prepared to function as PCPs. Yes, what they are doing is legal and accredited, and it provides education leading to primary care by chiropractors, but that doesn’t mean it’s adequate.

    2. WilliamLawrenceUtridge says:

      I don’t have to undergo a hypnogogic state to realize alien abductions aren’t real. I don’t have to undergo past life regression to realize past life memories are delusions rather than fact. I don’t have to be a chiropractor to recognize the fact that chiropractic practices, beyond spinal manipulation for back pain, is unsupported by science and that it is madness to claim it can cure asthma, colic, cancer or anything but musculoskeletal pain (making them specialist physiotherapists with delusions of grandeur).

      The recommendations for GERD are simply mainstream recommendations that do not involve drug treatment. It is chiropractors who pretend doctors only offer drugs and completely ignore that there is a tremendous number of drug-free recommendations for many chronic diseases (primary among them being exercise, weight loss and good diet); in cases where chiropractors recommend nondrug treatments, they are parasitic on the scientific literature, none of their recommendations come from clinical trials run by chiropractors. They just pretend they invented the treatment and hope nobody knows what pubmed is.

      Did you read the article and note that even this attempt to prove chiropractors could be PCP didn’t see anything close to the types of patients and conditions seen by real doctors?

      If courts were involved with the decision whether chiropractors could be PCP, it might be interesting. The reality is, chiropractors are attempting to use legislation, political lobbying, to force themselves into the realm. Legislation only requires the vote of politicians, not a review of the evidence.

  20. lizditz says:

    One thing I loathe and despise about chiropractors and “practice extension” is preying on frightened and vulnerable parents. They do it by various means, but here is a prime example: a packaged curriculum for chiropractors to use to expand their patient base to include autistic folk, presumably primarily children. The standard bunkum is a mere $40.00 and the premium bunkum is $100.00.

    Autism & the Brain-Body Connection is a comprehensive program designed to educate both the public and autism providers in your community on the impact of vertebral subluxation and the benefits of correction.

    The program is easy to implement and comes with:

    1 general public presentation
    1 presentation for autism healthcare providers
    15 page manual with step by step instructions for the successful promotion of the event
    Full access to future updated versions
    Premium version comes with the presentations, promotional flyers and graphics personalized as well as up to 10 edits of the date and location on the promotional pieces for up to 10 events.

    I shudder to think of an autistic child (or adult without the verbal capacity to refuse) with touch aversion and sensory issues being subjected (assaulted) by chiropractors.

    1. WilliamLawrenceUtridge says:

      Could you imagine the force required to adjust the neck of a struggling autistic child?

    2. lizditz says:

      Found a chiropractor who appears to have purchased and deployed the kit o’bunkum above. How is this for nonsense?

      If the information received by the proprioceptive system and other neurological components is interfered with in any way as it travels to the brain, then naturally, our ability to respond to that information appropriately will be affected.

      This is where a common physical condition known as vertebral subluxation comes into the picture for children within the spectrum and with other disorders as well. A vertebral subluxation is a misaligned vertebra affecting the function of the nervous system as the delicate spinal cord travels through the spinal column. This misalignment alters the information being delivered to the brain, the brain’s response and ultimately the quality of life of the individual.

      The quality of our lives is dependent upon the information we receive and whether or not we are able to respond appropriately. Vertebral subluxation is a major source of interference to the nervous system that goes undetected in the majority of children within the autism spectrum.

  21. Colin Davis says:

    I don’t know how many people here will have heard of Newsbiscuit. It’s sort of a British version of The Onion, and though it’s not quite as good as the American site at their best, it is pretty good, and this piece had me laughing aloud at one point.

    http://www.newsbiscuit.com/2013/10/20/free-schools%E2%80%99-unqualified-staff-idea-extended-to-%E2%80%98free-hospitals%E2%80%99/

    The reference to homeopathy is priceless.

  22. Colin Davis says:

    I don’t know how many people here will have heard of Newsbiscuit. It’s sort of a British version of The Onion, and though not quite as good as the latter at its best, it’s still pretty good.
    This article had me laughing aloud, particularly the reference to homeopathy.

    http://www.newsbiscuit.com/2013/10/20/free-schools%E2%80%99-unqualified-staff-idea-extended-to-%E2%80%98free-hospitals%E2%80%99/

  23. Medicine and healthcare, IMO, it’s a complex marriage between human nature, free will, the free market, free speech (even if it’s not the truth), free health care (we all pay into it but not all fully benefit), a for-profits health care industry, consumerism and raw capitalism. And no one guarding the hen house. :(

    Well guys, I see everyone is speaking different languages and understand the human body differently. I’ll throw my 2 cents into the chaos.

    To bad a lot of you don’t know Travell, Gunn, Rachlin and Cannon’s Law or try to treat complex pain patients. If you did, your paradigm would shift and you would see things differently.

    First lets clarify they are just two types of medical philosophies.
    … the dominant one which uses pills and the surgical blade.
    … And all the others.
    We know for certain that many pills and surgeries fail and thus our healthcare system is a failure for what it cost. We rank somewhere in the mid 30’s out of a few hundred countries. All based on erroneous theories, lies and deceptions. Our system has a lot to be desired.

    Chiropractors, MDs, DO’s, NPs, PAs and DC are all trained differently and can work harmoniously together to blend together a very unique and highly effective health care system. If not for egos, power struggles and the intense rivalry between the all sides, with no common ground.

    1. WilliamLawrenceUtridge says:

      I’m not sure why you recognize that health care is complicated, but present grossly simplified, mutually-contradictory, obsolete and wrong ideas about the human body as part of the solution. And while I have no problem with idiots wasting their money on placebos, the government has a role in shutting down ineffective and dangerous practices, as well as quality control, public health support and ideally health insurance companies should offer plans that do not include CAM as reimbursement options. While freedom of choice is a good idea, if that choice is based on self-serving lies and inaccurate information, that’s hardly a good thing, is it?

      I wouldn’t have a problem with treating complex pain using ethical placebos, if only you didn’t believe it. I actually support the use of acupuncture with certain patients, so long as the doctor is responsible and aware that it’s quite possibly just the brain modulating itself. Oh, and as long as the doctor is aware that it can’t cure anything but symptoms.

      First lets clarify they are just two types of medical philosophies.Why not clarify that there should only be one type of medicine (that which is proven to work), and the rest should be investigational only? Why pretend that two completely contradictory paradigms are somehow able to integrate? And how can the different professions harmonize when they are based on completely different starting points, explanations and treatments?

    2. windriven says:

      @Stephen Rodrigues

      You said, “Medicine and healthcare, IMO, it’s a complex marriage between…”

      Every single thing except the most important: SCIENCE. Not once did you mention science. You are not a physician. You are not a doctor. You are a shaman, an amateur, a joke.

      You go on to say that “Chiropractors, MDs, DO’s, NPs, PAs and DC are all trained differently and can work harmoniously together…”

      Tell me, no magic, no smoke or mirrors, what chiropractors and naturopaths have brought to the table? What diseases have they eliminated? Which technologies have they developed? Which naturopath developed the polio vaccine? Which chiropractic therapy brings sight to patients blinded by glaucoma? Which shaman eliminated smallpox? What is the homeopathic remedy that has turned AIDS from death sentence to manageable disease?

      You have nothing but mumbo-jumbo. All navel-gazing and empty talk. If medicine was as you imagine it we’d still be chasing evil humors.

  24. Just like modern medicine academics or wordsmiths (you guys) have fallen victim to the same falsehoods. First everyone completely ignores God in the equation and a lot of time the human body will auto-miraculously heal without human intervention. Second; What is an illness?? Even in the ER if someone comes in with abdominal pain RLQ is it appendicitis or one of the other 20 in the differential. Then surgical societies recommended to take a certain number of “normal” appendix to error on the side of saving the patient from rupture or sepsis. 3rd. What that scientific method is this called, we must take some normals so we don’t miss a real case??
    You must not glorify modern medicine, doctors or physicians as you do because nature should take a lot of the credit.

    There are many methods to study causes and effects. In modern medicine as here, the wrong methods are used and thus the erroneous results. You forget clinical trials come with errors and hopefully no one dies in this game.

    Medicine has gone thru an evolution mostly for profits under the guise of humanity. “You are not a physician. You are not a doctor. You are a shaman, an amateur, a joke.” Yes, I have to admit the names “doctors and physicians” are descriptions of someone who have been given the legal authorities use trials and error to hone their skill by making mistakes. Hopefully without doing permanent harm. Practicing and gathering experience is the key. If you want a Renal Specialist don look here, if you want someone to treat your RSD/CRPS or frozen shoulder, I am the “expert.” The quotes are used because I am only an expert if I can actually help someone. What you guys are describing in medicine is a system that has tried and tested many poisons on the likes of the innocent to figure out which will do some good and not poison, maim or kill.

    If you really wanted to improve the present state of affairs, you would ask the appropriate questions. But then you would have to unsettle your present paradigms and have nothing else to do.

    1. WilliamLawrenceUtridge says:

      First everyone completely ignores God in the equation

      There’s no proof that God exists, and if belief in a deity were curative, doctors would be redundant to priests. They are not.

      a lot of time the human body will auto-miraculously heal without human intervention.

      What’s miraculous about the body healing? What kind of evolutionary sense would it make to have a body that never healed itself?

      Second; What is an illness??

      Yeah, there’s a multitude of ways the body can get sick, the real issue here is how to heal it. Modern medicine tests interventions to determine whether they work, keeps the ones that do, and drops the ones that don’t. You want to regress to a time when personal opinion is more important than evidence – that will lower life expectancy by a tremendous amount, since it will bring us back to the days when life expectancy was far lower. Your insistence that “what works for my patients” is superior to a clinical trial is dangerous.

      You must not glorify modern medicine, doctors or physicians as you do because nature should take a lot of the credit.

      Why wouldn’t we glorify modern medicine as an approach? Individual doctors can fail and become overly-enamored of their own opinions (you are an example), but as a whole, it works really well, again as evidenced by life expectancy, the extinction and control of diseases, and all the other successes of medicine.

      And what is your substitute? Because it appears to be the glorification of your own opinion. Why is that better?

      There are many methods to study causes and effects. In modern medicine as here, the wrong methods are used and thus the erroneous results. You forget clinical trials come with errors and hopefully no one dies in this game.

      Clinical trials do come with errors, which is why doctors rely on the collective scientific evidence. Do you know what else comes with errors? Personal experience and anecdotes. Do you know what corrects for the errors of personal experience and anecdotes? Clinical trials, scientific controls, systematic reviews – the exact things that show that acupuncture, one of your preferred treatment modalities, doesn’t work.

      Medicine has gone thru an evolution mostly for profits under the guise of humanity.

      I’m sorry, do you provide your services for free, or you a hypocrite?

      What you guys are describing in medicine is a system that has tried and tested many poisons on the likes of the innocent to figure out which will do some good and not poison, maim or kill.

      Yes, medicines can be poisonous at high doses. That’s why they are tested to establish pharmacokinetics, pharmacodynamics, LD50 and other measures of toxicity and effectiveness, not to mention post-marketing surveillance.

      What’s the system to track lung punctures due to acupuncture needles?

      Also, I would be dearly interested in your solution, your superior testing intervention, over clinical trials. Surely with all your criticisms, you’ve got something superior to offer? Because otherwise, you’re really just engaging in some egregious self-justification to preserve ego and income.

    2. Dave says:

      Your comments on appendicitis are at least 20 years out of date. CT scanning has greatly increased the accuracy of diagnosing an acute appendix. Your figures are from the time when physical examination and the history were the only ways of diagnosing the problem, and there are some mimics of appendicitis as you seem to be aware. The issue back then was that it was safer to operate on someone who turned out to have mesenteric adenitis than to withhold surgery and have a septic patient from a catastrophic ruptured appendix.

      Mainsteam medicine has a pretty good idea of nature’s ability to heal. Do you really think that doctors are unaware of the natural history of disease?. If you seriously believe this then you should pick up any general medical textbook and read a few chapters, especially the epidemiology, natural course and prognosis sections on any given disease. Actually a lot of general practice is to decipher when medication is needed and when they should not – doctors spend a lot of time talking patients out of taking antibiotics for colds, for example. Another example – it is well known that 90% of patients with low back pain are better in a few months regardless of the intervention, even just reading a pamphlet on low back pain. On the flip side the rate of natural healing for bacterial endocarditis is zero percent. No patient in the pre-antibiotic era with this condition ever survived. I wouldn’t bet a wooden nickel for bacterial meningitis to heal spontaneously, either. In the pre-antibiotic era bacterial pneumonia was called (by Sir William Osler) “the captain of the men of death”. You should also be aware that much of the care of chronic (by definition incurable) diseases is to improve the quality of life of the patient as well as hopefully the length. I wouldn’t get into a discussion with a doctor as to the natural history of diabetes, various cancers or multiple sclerosis. He or she is all too aware of that.

      But stick to your natural healing if you get sick. Nobody forces you to see a doctor.

      1. WilliamLawrenceUtridge says:

        Considering his ideas about prescientific medicine are a good century or more out of date, 20 years sn’t that bad…

    3. windriven says:

      “First everyone completely ignores God in the equation”

      God is dead. Didn’t you get Neitzche’s memo?

      ” a lot of time the human body will auto-miraculously heal without human intervention. ”

      Apparently the irony of you making this assertion is lost on the asserter. That is without question the funniest thing I’ve encountered all day. It isn’t medicine that doesn’t understand regression to the mean, it is shamans and hand-wavers who see regression to the mean and claim it as proof of the power of their quackery.

      “You forget clinical trials come with errors and hopefully no one dies in this game.”

      Again you demonstrate your naivete. In the first place one point of clinical trials is to establish the efficacy and safety of a procedure or drug once with one set of patients in a carefully controlled setting. What you advocate is every two-bit “healer” experimenting on his or her patient population in an entirely uncontrolled circumstance. Whatever you “learn” is mixed in a thick soup of confirmation bias and misunderstandings of basic biology and science in general.

      “There are many methods to study causes and effects.”

      No. You are wrong. Dead wrong. There is precisely one method – the scientific method and its usefulness and validity have been demonstrated over and over again. Only the thick of skull and thin of intellect fail to grasp this.

      1. If science answers all questions beyond doubt, then why do we have illnesses, disease, failed surgeries and therapies?

        Humans exist and are living inspite of what someone thinks, believes or the scientific methods.
        Only the naive accepts science as absolute. Two key inextricable variables of any scientific study are human nature which has the potential of invalidating most studies and natural “auto-miraculous” healing. So I think what you are suggesting is a way to gather information to persuade someone to pay good money for something that they don’t need. You are not referring to science but commerce.

        The reason I am here is to shed light on combined therapeutic options from a few pioneers in medicine, blending what works into a package. I do have experience in both traditional and complementary medicine have witness the inhumane and the best of both worlds. I treat patients who have failed surgery with this therapy that is very effect at controlling pain and elevating well being contributing to a better quality of life. Maybe that is not what all of you are here for except to promote and validate the commercial aspects of medicine.

        1. Harriet Hall says:

          “If science answers all questions beyond doubt,”
          “Only the naive accepts science as absolute.”

          Where did you dream up those straw men? The very essence of science involves never being beyond doubt and never claiming to have absolute answers, but to adjust the answers as new data become available. On the other hand, science is the only reliable way to investigate reality and to decrease the degree of doubt.

          1. Yes as technology improves our models have to change. So by now science should have proven beyond a doubt that Acupuncture or Chiropractic adjustments are completely ineffective. But you will not find it and never will. We will find out that it is valid therapy. I agree you can question the philosophy surrounding those disciplines but that does not invalidate the results in clinical practice.

            “science is the only reliable way” which is true because science is in the eye of the beholder, in it’s most simplistic sense. Observation collects the raw data for any study. You can’t study what can not see, refuse to see or understand. I can see and feel the feedback data from an acupuncture needle much better than you guys. A football scout can see the abilities in an athlete better than I can. You can’t invalidate my observations just because you are inept.

            1. MadisonMD says:

              I can play this game too:

              So by now science should have proven beyond a doubt that Santa does not exist. But you will not prove it and never will. We will find out that he exists. I agree you can question the philosophy of flying reindeer but that does not invalidate the results on Christmas Day.

              “science is the only reliable way” which is true because science is in the eye of the beholder, in it’s most simplistic sense. Observation collects the raw data for any study. You can’t study what you cannot see, refuse to see or to understand. I can see and feel the presents I get from Santa much better than you guys. A football scout can see the abilities in an athlete better than I can. You can’t invalidate my observations just because you are inept.

            2. windriven says:

              You don’t learn, Rodrigues. Shut your pie hole for 5 minutes and contemplate the contributions of medicine to the contributions of the whole array of sCAMs. Medicine has vanquished smallpox, polio, measels, diptheria, rubella, pertussis,. It has developed surgical cures for everything from aortic aneurysims to cholecystitis to appendicitis. It has reduced AIDS from death sentence to manageable chronic disease and moves ever closer to a cure. It routinely saves tiny preterm babies and replaces diseased organs like kidneys and livers. And chiropractic and acupuncture have delivered what?

              You disgust me. Your delusions of grandeur disgust me. You are a jackal who lurks in the shadows at the edge of the herd. In a more egalitarian society with universal quality healthcare you would be reduced to dealing three card monte on the street corner.

            3. WilliamLawrenceUtridge says:

              So by now science should have proven beyond a doubt that Acupuncture or Chiropractic adjustments are completely ineffective.

              By that rationale, they should also have been proven effective. However, ongoing research, particularly more recent, better-controlled research, has shown that it doesn’t matter where you put the needle, it doesn’t matter if you penetrate the skin, but it does matter if the therapist is nice or not. What else is left? Being nice to patients is something known to doctors for millennia.

              You can’t invalidate my observations just because you are inept.

              Your inept understanding of science and scientific controls can’t validate your opinions though. I have no doubt that you get good results with your patients. Confidence, elaborate rituals, complicated babble, the desire not to disappoint an admired professional, getting better because you made the appointment when you were feeling your worst, all of these things can lead to patients saying “I feel better”. But that doesn’t mean that the specific acts undertaken in the minutes they are within your care are responsible for any objective improvements. Again, I ask two questions:

              1) What kind of doctor are you?

              2) How do you reconcile your experience with the fact that well-controlled research consistently fails to find long-term, objective benefits for the interventions you champion?

              I mean, aside from discounting science because it is inconvenient to you?

        2. windriven says:

          “Two key inextricable variables of any scientific study are human nature which has the potential of invalidating most studies and natural “auto-miraculous” healing.”

          You braying ass. You claim that human nature has the potential of “invalidating most studies” but you appear blind to the well understood human proclivity for confirmation bias. Science – and I really wish you had some basic understanding of science – has developed a careful strategy to exclude that bias called double blinding. But Rodrigues the Magnificent has no use for such things because he is omniscient and he alone can ascertain what is good and what is not. Bite me.

          And WTF is “auto-miraculous healing” supposed to mean? There is nothing miraculous about it. Evolution since time immemorial has built that into the program. Do you suffer under the delusion that every time you nick your finger some deity is there to prevent infection? What’s the deal when something does get infected? Was god off on a coffee break? When coffee was over and god realized there was an infection was it too hard to ‘cure’ or did god just not give a crap? Good thing Crislip was there with a syringe full of penicillin, huh?

          1. Human errors present themselves in many forms of bias. You can’t really factor them out even in double blinded studies. And as your know repeating a study that involves humans subjects, will not result in the same conclusions. I will sometimes get a patient who add “sugar” to my therapy and will tell me, “oh doc that feels better already,” but them I will talk to a loved one the following day and they will tell me the truth. “She said that so she would not get stuck anymore.” Acupuncture is actually surgery and in future studies I would want them compared to an actual surgery like for lower back pain or knee pain. The needles will win every time!!!

            Oh, when you cut yourself nature heals automatically. Add in a few extra bacteria and your body will naturally fight them off or it will not. Add in a helper like penicillin which will decrease the bacterial load so the body can do it’s thing. The antibiotic can do diddley without a good working human body. Wait too long and even the antibiotics will do nothing. Gee medicine is not magic, it only assist the body.

            1. windriven says:

              “Human errors present themselves in many forms of bias. ”

              You know, you really need to take a step back, look at yourself in the mirror, and repeat that over and over until you actually understand it.

              That said, I am done with you. Your ignorance is refractory. Your arguments are banal. Neither light nor even heat comes from our discourse.

              I can only say that I have pity on those who seek your care.

            2. WilliamLawrenceUtridge says:

              Human errors present themselves in many forms of bias. You can’t really factor them out even in double blinded studies. And as your know repeating a study that involves humans subjects, will not result in the same conclusions.

              Actually, you’re highlighting the very reason why double-blind studies are required, along with randomization and large groups (the latter two particularly important because an adequate number of subjects “washes out” much of the variability exhibited by individuals, as well as ensuring there is no systematic bias in the creation of the groups). If a study is repeated and the results are completely at odds with another study – that suggests the effect is not real and the treatment should be abandoned. It is only when a signal arises consistently from the noise that a treatment should be promoted and widely adopted.

              Also, given the problems of bias inherent in controlled research, I’m not sure how your apparent solution of abandoning all controlled testing is supposed to be an improvement. Medicine, before the scientific method, had no testing or controls – it was all based on gut feelings and experience of doctors. How well did that work? How well-controlled were smallpox and polio back then, how long were lives? Perhaps modern science isn’t very good at dealing with chronic pain and lifestyle conditions, but then again – compared to what? How much did prescientific medicine offer? Not to mention part of the “problem” is people don’t die of infectious disease and trauma, thus living long enough to develop arthritis and other pain conditions.

              Acupuncture is actually surgery and in future studies I would want them compared to an actual surgery like for lower back pain or knee pain. The needles will win every time!!!

              The fact that you state this with certainty rather than stating “I believe the needles will win every time” rather illustrates the problem – science is only valid if it justifies a belief you already hold. Science doesn’t work that way, it’s iconoclastic, it challenges preconceptions.

        3. WilliamLawrenceUtridge says:

          About as smart and thoughtful a question as “if humans evolved from monkeys, why do we still have monkeys?”

          Diseases exist because all life on Earth is part of a competitive process of evolution which involves the competition for resources. Human flesh, for bacteria (and predators) are one such resource.

          Science is a systematic effort to test different types of interventions to determine if they work. Consistently, it shows that your pet intervention of acupuncture could be done more safely and just as effectively without any skin penetration, and with zero training or attention to where the needles are placed – all that matters is practitioner confidence. Science hasn’t answered every single question because science takes time, iterations, and resources – and there’s a lot of questions that require answering. Your caricature, childish understanding of science seems to say that if science can’t be perfect, it must be worthless. And that’s why you are an idiot.

          Only the truly naive think that their opinion can be trusted more than the scientific process. Naively-held, untested opinions were responsible for bloodletting, purgatives, homeopathy, acupuncture, chiropractic and related CAM interventions, which take money from patients and offer little in return beyond placebo and a form of emotional coping.

          As for your treatment approach, didn’t you say a while back that you focused mostly on pain? Particularly back pain? Back pain gets better on its own, basically in spite of every intervention that you might take. Congratulations, you have exactly the same effectiveness as watchful waiting. Take pride in that.

          1. The logical conclusion is we evolved from diverging from a “monkey-like” creature. Duh … how can we evolve from an animal that is at the same evolutionary level we are.

            I’m amazed that people will tell me that my practice is invalid and not tested when I and my patients witness the improvements first hand.

            Science comes in many forms and it is not perfect. The problem we are having now it that some will use this “perfect science” to dictate healthcare and medical practices. Flawed logic, good for the bottom line not for patients. My beef with healthcare and capitalism is that one feeds on the other is a symbiosis like way. If a fairness referee wants to change things, all hell breaks loose and lies start to fly. I wanted alternative to be a part of the ACA, but they are not, so down into the hole we fall. Are you guys spreading lies and misconceptions about alternatives?? Because that would be wrong to allow folks to suffer without the best possible care like needles and hands on care.

            Did you know we still use bloodletting and leeches?? They both are safe and highly effective. There are some alternatives I have not investigated in the real world, but needles are the best medicine in medicine.

            It is true that a lot of times back pain will get better in spite of modern medicinal options. A healthy human body has a Natural way of healing itself … just get out to the way. And don’t run someone to the surgical suite to take advantage of the natural event. I’ve seen so many failed back surgeries over the decade, I have put on record that I will not promote or advocate for them. Shoulder, hip, elbow, hip and knee surgeries too. Nada … if I had the know how I would have Trial lawyers intervene to keep patients safe from the surgeon’s blades.

            1. WilliamLawrenceUtridge says:

              Yeah, it’s about as sensible a question as your original “If science answers all questions beyond doubt, then why do we have illnesses, disease, failed surgeries and therapies?” Can you think of what might be the answer to that question?

              What kind of doctor are you?

              Also, there’s no such thing as an “evolutionary level”. Humans are not “more evolved” than any other animal or plant. The idea of a “chain of being” with humans at the top was a religious preoccupation used to justify the egotistical position that humanity was the pinnacle of creation. We’re not, but we are relatively easily killed by a wide variety of micro-organisms.

              I’m amazed that people will tell me that my practice is invalid and not tested when I and my patients witness the improvements first hand.

              Witchdoctors, bloodletters, homeopaths and acupuncturists say exactly the same thing. People also claim first-hand experience of alien abduction, demonic possession, CIA-broadcast mind control rays, life after death and a host of other improbable or impossible events. I’ll ask you a question that I’ve asked you many times before – why do you think scientific testing consistently fails to find any objective benefit to the modalities you are so enamoured of?

              Science comes in many forms and it is not perfect.

              Well duh. That’s why findings and conclusions are tentative, there exists a peer-review process, there are increasing calls for open access to raw data, there is a process to withdraw certain papers, there are meta-analyses, replications, expert panels and the like. Who claims that a single study is enough to justify a practice?

              And why is your personal experience superior to science? Why doesn’t scientific research match up with your personal experience? Why would removing the controls and correctives found in science lead to more reliable information?

              The problem we are having now it that some will use this “perfect science” to dictate healthcare and medical practices…My beef with healthcare and capitalism is that one feeds on the other is a symbiosis like way.

              No science is perfect, which is why expert guidance and similar documents are updated as new evidence becomes available. But even imperfect science is still far superior to impressionistic medical practice. Again allow me to remind you that medicine as practiced before scientific medicine was essentially unchanged for millennia, but live expectancy didn’t improve and disease incidence didn’t decrease until the advent of scientific medicine.

              I wanted alternative to be a part of the ACA, but they are not, so down into the hole we fall.

              You’re claiming alternative medicine not being in the ACA is a bad thing – why? There is no proof that alternative medicine improves objective outcomes, making it an expensive form of counseling at best (so long as the practitioner doesn’t puncture a lung, or discourage vaccination, or sell expensive, unnecessary supplements). Why should the government pay for it?

              Are you guys spreading lies and misconceptions about alternatives?? Because that would be wrong to allow folks to suffer without the best possible care like needles and hands on care.

              Why are we spreading lies? Because we reference the scientific literature, which consistently finds that alternative medicine is ineffective and has unappreciated dangers?

              Real medicine has both needles and hands-on care, thank you very much. It sounds like part of your problem is mixing up the economic problems of American health care (which are terrible, the US needs a real health care system) and the complete lack of scientific evidence for the quackery you charge your patients for. What would be wrong would be exposing patients to the risk of treatments with no benefits, and charging them for the privilege.

              A healthy human body has a Natural way of healing itself … just get out to the way.

              By the FSM you are an idiot.

              What is the natural way the body has of healing from Huntington’s disease? PKU? Cystic fibrosis? HIV infection?

              How does “getting out of the way” help with polio, or smallpox?

              What you seem to reveal with comments like these, is that you may deal mainly with self-limiting conditions that will get better on their own. You appear to specialize in the “children’s table” version of medicine.

        4. WilliamLawrenceUtridge says:

          If science answers all questions beyond doubt, then why do we have illnesses, disease, failed surgeries and therapies?

          You might have a point here, when science is finished learning everything about everything. Since science isn’t yet omniscient, your point is specious – and doesn’t excuse substituting whatever fantasy takes your fancy instead.

          Humans exist and are living inspite of what someone thinks, believes or the scientific methods.

          Are you alluding to some sort of “the mind creates reality” idea? Because if the mind creates reality, then someone was a real bastard to come up with smallpox. The mind does create sensations of pain, which can be relatively attenuated with placebo effects as well as with pills, and it is science that shows us the difference between a change due to the intervention versus a change due to placebo. You find this inconvenient, but that doesn’t mean your opinions overrule reality (which is a honey badger).

          Two key inextricable variables of any scientific study are human nature which has the potential of invalidating most studies and natural “auto-miraculous” healing. So I think what you are suggesting is a way to gather information to persuade someone to pay good money for something that they don’t need. You are not referring to science but commerce.

          Yeah, no. Human nature and natural healing are the reasons why you need careful scientific testing. Otherwise, all you can say is “I did this, and that happened”. Which means you have no idea if “this” caused “that”. You may be very impressed by this, but that just means you are naively convinced of your own ego-preserving rationalizations. Real scientists realize that skepticism is the only path to real knowledge.

          You really think that bloodletters and priests from centuries past were not convinced of their own ability to heal?

          I treat patients who have failed surgery with this therapy that is very effect at controlling pain and elevating well being contributing to a better quality of life.

          How long is your follow-up? How do you know they didn’t simply go back to their usual painful state, get discouraged and never bothered going back to you?

          Maybe that is not what all of you are here for except to promote and validate the commercial aspects of medicine.

          I’m sorry, do you deliver your services for free? If so, at least your patients are getting what they pay for – confidence and illusion.

  25. Dave says:

    The last time I heard of anyone who has any understanding of science claiming that “science answers all questions beyond doubt” was a physicist (his name escapes me) in the late 1800′s who advised young people to avoid entering physics, because apart from a few unsolved problems such as the photoelectric effect, all major discoveries had been made. Since then physicists have discovered special and general relativity and the whole field of quantum physics. I think you need to take a basic science course. You accuse scientists of being naive, but you are SO misinformed.

    In an attempt to educate you, the following are a few medications which are rarely or never used because scientific studies have found they are not effective in preventing death or clinically important endpoints (translation – studies have DECREASED or eliminated the sale of these meds, in direct opposition to your statement – “Maybe that is not what all of you are here for except to promote and validate the commercial aspects of medicine.”)

    Encainide and Flecainide for arrhythmia suppression
    Torcetrapib for cholesterol llowering
    Probucol for HDL raising
    Atromid for cholesterol lowering
    erythropoieten for hemoglobins above 10 but less than normal
    Calcium channel blockers for acute MI’s
    The addition of ARB’s to ACEI for CHF
    Milrinone, flosequinan and vesnarinone for improving cardiac contractility
    Several gitizones for diabetes
    nesiritide for congestive heart failure

    This is off the top of my head and by no means exhaustive.
    Science is to determine in medicine what works, and what does not. If you have a particular modality, be it prayer, a particular herb, or whatever, which can be shown in a randomized, controlled and reproduceable study to improve outcomes, then do the work, get the study published, and if it is substantiated it will become mainstream. If you have such a modality and do NOT do this, you are guilty of withholding that modality from the vast majority of people who could benefit from it (as has been repeated endlessly in this blog).

    1. Yes we must use the scientific methods to test chemicals in humans. This is logical. In this case these are good meds and have been tested to determine the risk-benefits are acceptable.

      You seem to know cardiology well…
      What about stents?
      and All those EGKs that I did for all those yrs that yielded nothing but extra income for my employers.

      I know low tech hands on and needle therapy for pain. I practice the traditional way and saw the failure mount. With needles you can harm and the needles are actually the best tool to treat myofascial pain problems.

      Another issue is pain will not kill and you can see it with the eye or scan, so it can be negated and discounted, so patients will suffer. Why will HC pay 1000/mo for med to keep someone living a few more months but will not allow a few therapeutic sessions to give someone a better quality of life??

      1. oop …
        needle can not harm except for a little ouch.
        A failed thumb, wrist, shoulder, spinal, thoracic outlet surgeries will devastate a person’s life.

        Why are these guys in this blog so certain that science has all the answers. What about fairness and equitability in medicine.

        I bet if patients had to pay for what they thought was a good product, a lot of specialist would be out of business.

        1. WilliamLawrenceUtridge says:

          needle can not harm except for a little ouch.

          Do you know who Kim Ribble-Orr is?

          Why are these guys in this blog so certain that science has all the answers. What about fairness and equitability in medicine.

          What about it? Science is fair – it tests blindly, repeatedly, and asks only for good data. Meanwhile, you have never explained why your experience doesn’t match up to the scientific data, or why your experience is superior to scientific testing, or why your personal certainty and incredulity is better than a blinded trial. As for why we are certain science has all the answers – we aren’t. You keep pretending we say “science knows everything” despite repeated comments noting science is always tentative (as opposed to your dogmatic certainty that your own experience is the best and most reliable guide to medicine).

          Also, it sounds like your version of “fairness” is “I get an equal chance to eat at the trough”. Which is amusing given your consistent accusations of greed on the part of every other doctor on the planet.

          I bet if patients had to pay for what they thought was a good product, a lot of specialist would be out of business.

          Yeah, but patients are basically idiots – they fall for confidence men like you (i.e. “I’m confident this will work” being enough to convince them to open their wallets). You seem to be advocating for “demand-based medicine”, whatever is popular, wins. Well, horoscopes are popular, should we base economic and political decisions on them? Popularity bears almost no relation to effectiveness, what you are asking for is a return to the days before the FDA, when snake-oil salesmen hawked their wares from town to town with no controls or evidence. Why is that better? Aren’t you just asking for the opportunity to grow your practice without any checks on whether or not you are helping patients? How arrogant (and greedy).

      2. Dave says:

        Studies have clarified when stents should and should not be used. It has been proven they do not prolong life or change mortality in patients with stable angina (COURAGE trial), a trial which has decreased the numbers of stents placed. SBM again decreasing an expensive intervention.

        As far as EKG’s, it is often extremely helpful for me to have a baseline ekg available. If a patient presents with chest pain to an ER and his EKG shows a LBBB, the treatment is quite different if the LBBB was present on previous ekg’s than if it is new. Knowing if a patient has a prolonged QT interval may factor in what antibiotic I would prescribe for an infection. Never assume that a normal study is useless as it may guide treatment decisions down the road. EKG’s are painless and should be cheap.

        Again, this blog is about science based medicine. Medical economics, politics, ethics and philosophy are worthy subjects to discuss but are not really addressed in a blog related to the evidence of whether treatment does or does not work. “Fairness and equitability” in medicine are important but belong in a different forum.

    2. The issue realted to doubt was realted to http://www.sciencebasedmedicine.org/acupuncture-doesnt-work/

      Meaning if Acupuncture does not work it would have been proven beyond a doubt or placebo.

      So the way you win or discount an argument is to belittle the knowledge of the other person. That is truly not fair way to get at the truth.

      Yes … I do need more study … that is my journey!
      Yes … scientist (some) are naive!
      No … I am not inexperienced in the practice of needles. In actuality y’all are the naive ones in this regard.

      1. WilliamLawrenceUtridge says:

        The way the patient wins is by science testing and discarding, or improving, medical interventions to become more effective, more safe, more efficient, less costly, more timely, and so forth.

        A treatment that fails to perform beyond placebo should be discarded. The fact that one treatment happens to be your pet treatment, and a source of income for you, doesn’t mean that you get to exclude it from scientific scrutiny or dismiss inconvenient studies.

        And that’s what this is really about – you don’t want to believe that your pet treatment, your personal favourite, is ineffective. So instead, you attack science. You claim bias. You move goalposts. You special plead. You do everything you can to avoid admitting or acknowledging that you have been practicing an ineffective therapy for years.

        Rather classic cognitive dissonance.

  26. Dave says:

    I should point out that this blog is a “science based medicine” blog. It is not a metaphysics or philosophy blog.

    1. Dave, how does one tease out all the disciplines of science and not use the language of metaphysics and philosophy. I would imagine, if we are referring to an atom we can strictly converse in raw scientific terms. When we are designing a drug study we can construct it based on a scientific model, but to implement the study we are actually experimenting with humans. As you know humans add in the dimensions of emotional, ethical, social, environmental and political components. ie What if we are studying drug X effectiveness for problem Z but the patient dies during the experiment as a direct result of drug X. Help me to explain this to the family of the dead person. These deaths happens all the time in clinical practice but are discounted as the cost to find the truth.

      I’m stumbled to this blog when someone linked it to me regarding Acupuncture. I thought I could help since I have 15 yrs experience in the branch of alternative therapies. I was hoping to contribute my resources, articles, textbook and my testimony from the front lines, hands-on, trials and error as a seasoned practitioner. Who else can help to clarify the definitions of these disciplines so that the conclusions will be a bit more precise. You would be the go-to person for cardiology and internal med. For example, In ‘97 my definition of Acupuncture is different than it is today. So when I read a study that uses Acupuncture I can detect bias differently than anyone in this blog.

      I know and have witness so many failed orthopedic surgical procedures which is “the standard of care,” I now consider them malpractice. The scientist will say these sacrifices are necessary to get to the truth. Why are we still having failures if we know they will fail or not even try to find out why.

      But somehow, the raw scientist here tend not to believe another’s clinical experience. This is not a good means of finding the truth. I have few simple significant clues and the clues are under our noses blinded by the raw scientific methods. (they are simple, too simple and thus unbelievable for some academic minds)

      1. WilliamLawrenceUtridge says:

        As you know humans add in the dimensions of emotional, ethical, social, environmental and political components. ie What if we are studying drug X effectiveness for problem Z but the patient dies during the experiment as a direct result of drug X. Help me to explain this to the family of the dead person. These deaths happens all the time in clinical practice but are discounted as the cost to find the truth.

        While this is relevant to the clinical realities of scientific medicine and research, it is irrelevant to the testing process of the data. It would be nice if clinical trials, and medical treatment could occur without any deaths, but since no living thing has evolved to live forever, death is inevitable. This is why generally clinical trials also offer free medical care and supervision, as well as multiple phases to monitor for acute toxicities in both animals and human volunteers. It’s also why the best, highest-quality trials have predetermined stopping points if there is evidence that harms outweigh benefits (the Women’s Health Initiative is one such example; based on the “personal experience” of physicians, millions of women were getting estrogen replacement therapy – which it turned out was killing a substantial number prematurely, a fact which caused the early termination of the treatment arm).

        But what’s your response – stop all scientific testing because you feel bad when someone dies? Do you realize that this dooms millions to early deaths, because you couldn’t test new forms of chemotherapy, clot-busting drugs, antibiotics, etc? What’s your solution, acupuncture?

        I thought I could help since I have 15 yrs experience in the branch of alternative therapies. I was hoping to contribute my resources, articles, textbook and my testimony from the front lines, hands-on, trials and error as a seasoned practitioner.

        Yes, and it turned out that like so many practitioners of alternative medicine, it turns out your treatments are worthless beyond a form of expensive emotion-focused coping. It turns out you weren’t keeping up with the scientific literature, you were ignoring negative studies, and you were over-relying on your own experience. A real doctor who did this would lose their license, but since acupuncture is basically a free-for-all, and you don’t care as long as your patients keep rolling in, who cares? You certainly seem to be happy to ignore and discount the evidence so long as you can keep charging for your services and gratify your ego.

        ou would be the go-to person for cardiology and internal med. For example, In ‘97 my definition of Acupuncture is different than it is today. So when I read a study that uses Acupuncture I can detect bias differently than anyone in this blog.

        My definition of a go-to person for cardiology and internal medicine would be someone aware of both the positive and negative trials for specific treatments. You only have one half of that statement.

        Also, if you’re so great at picking up “bias” in studies, why not identify some? How can you be sure these studies are flawed, and you’re not just indulging in a “no true Scotsman” fallacy? As in “any scientific testing of acupuncture that fails to find a benefit isn’t really acupuncture”?

        I know and have witness so many failed orthopedic surgical procedures which is “the standard of care,” I now consider them malpractice.

        Yes, the contributors to this blog also consider this malpractice. They point out quite frequently that scientific testing for surgical modalities is difficult, but also inadequate.

        How does this justify defending the extensively tested acupuncture? If any surgical intervention had a tenth, a twentieth the number of trials of acupuncture, it would be considered so well-validated, or well-debunked, it wouldn’t be worth discussing. Yet you keep harping about acupuncture.

        But somehow, the raw scientist here tend not to believe another’s clinical experience.

        Actually, most of the contributors and commenters who are medical professionals are also clinicians. Dr. Gorski is a clinician-scientists. Dr. Hall was a family practice doctor. Dr. Novella is a clinical neurologist. Dr. Crislip is a clinical infectious disease specialist. Scott Guvara is a practicing pharmacist. What unites them is the understanding that their clinical experience is inadequate, and often deceptive. Learn from them.

  27. Dave says:

    Too bad you can’t edit after posting. I should edit my previous post – studies have shown stents show no improvement in mortality for stable angina over good medical care, not over doing nothing. And there may be quality of life issues directing certain people to get stents who would be candidates for either mode of therapy. None of this applies to patients with unstable disease or an acute coronary syndrome, which need urgent/emergent intervention. (My post is not to be construed as advice as to when to or not to get stents)

  28. Dave says:

    The trouble with one person’s clinical experience is that the numbers treated by one individual are too small to be meaningful. Example – the therapy for strokes is limited and not very efffective, but thrombolytic therapy in carefully selected individuals (most patients presenting witha stroke do not meet the criteria for one reason or another) can limit the size of a stroke and decrease the chance that the patient will wind up in a nursing home. There is no difference in mortality, but there is in disability. The therapy causes intracranial bleeding and death in some individuals who get it, but again the mortality in the treated and untreated group are the same. For every patient who dies from the therapy another is saved by the therapy. Obviously this therapy requires a long discussion and informed consent before it is given. My personal experience with thrombolytics started in a hospital which was part of the original stroke trials. The first patient we contemplated giving the drug to met the criteria, the TPA was drawn up and poised to be given and ten seconds before the drug was given the patient’s symptoms cleared, so we did not give the drug. If I had given the drug one minute earlier I would have thought it was a wonder drug. On the other hand if my first patient had a massive intracranial bleed and died I would be skewed the other way. You need large numbers of patients to see whether meds like this are effective and to sort out the risk/benefit profile. One individual cannot gain the numbers required. One’s individual experience can be reason for a hypothesis that can be further tested – example, Dr X gives alpha blockers for hypetensin to several patients with prostatic hypertrophy and they report they pee better. It can then be tested as to whether this is a real effect. Or, several doctors report that they have seen young men get a rare form of cancer called Kaposi’s sarcoma. Could there be an underlying factor present ?(these observations and others like it led to the discovery of AIDS).

    As far humans having individual characteristics and emotional states which affect outcomes, that is the reason we have placebo controlled, double blind (the enthusiasm of the doctor or provider also skews outcomes) randomised studies – to even out these types of effects.

    There are some drugs so effective that studies have been published with only a few hundred patients. An example is a study published in 1948 testing the effectiveness of streptomycin in tuberculosis patients (those of you out there decrying the benefits of medicine might be too young to remember the dedicated tuberculosis hospital that used to dot the land. The one in the city I trained in was closed down when I was in medical school.) Such drugs are few and far between. Most studies require thousands of patients to be statistically accurate.

    1. Modern medicine has truly advanced in medications, acute, critical care and surgical techniques BUT, it’s has lost the human side in the quest to find … gee what is it you are trying to find?

      How is this group defining “science,” as in Science Based Medicine?
      Is it just the Gold Standard double blinded experiments that you guys will accept as true?
      How is this Finding what actually is truely helpful to humanity.

      Conclusions;
      1. Observation is a necessary part of the scientific method. My observation is that there are too many failed back surgeries and how many more will humanity tolerate before we acknowledge the obvious. Something is wrong with this option. The true problem is embedded into the the muscles as per the authors Gunn, and Travell/Simons. The problem can only be felt by the patient. It can not be seen on the MRI and all of this is totally being ignored by the scientific community. (I’m still waiting for someone to ask me how I use Acupuncture in my practice!!)

      2. Ignorance is a necessary part of our present methods that we are using under the guise of “Scientific Methods.” I have a case where the surgeon did not read the chart for the chief complaint and only looked at the MRI and “fixed the wrong side. The patient’s pain was opposite the scan results.

      3. Human sacrifice is part of the scientific method. A patient’s death is more humane than to cripple them for decades. I had a patient who was bedridden for 2 yrs and none of her providers, touched her on follow up, listened to her complaints or questioned their own logic. My simplistic logical care was able to get her out of bed and active again. Nothing magical just stupidity and disrespectful of her other docs.

      4. God in not part of this scientific method. Supplements that actually do nothing except by time taking advantage of nature’s Innate healing is a multibillion dollar a year industry.

      5. Trial and error or try and see what happens is a necessary part of science. The beauty of Needle therapy is that it is safe so one can actually use the needles as a tool to probe and find the problem tissues. Sort of like a multipurpose-tool!!

      1. windriven says:

        1. Scientific observation is rather different than your self-serving anecdotal gawking;
        2. There is nothing necessary about what you characterize as ignorance. Mistakes happen but medicine goes to great lengths to study mistakes and create protocols to prevent future ones. It is asinine to suggest that, because humans sometimes err, that science is wrong or that idiocy is somehow better;
        3. “A patient’s death is more humane than to cripple them…” That isn’t your choice. And again, the human failures of medicine don’t have anything to do with the systemic failure of sCAMs.
        4. God is a personal fantasy. If it gets you through the day, that’s nice.
        5. What you call “Needle therapy” causes infections and prevents people from seeking medical care. It is not a multipurpose tool it is hocus pocus. MRI is a multipurpose tool. Computed tomography is a multipurpose tool. Ultrasound imaging is a multipurpose tool. Needles are useful for sewing and, in the hands of con men, for separating the vulnerable from their money.

      2. Dave says:

        I agree there are many failed back surgeries. You don’t see the ones that are successful. For a back surgery to work the diagnosis must be correct (operating on an asymptomatic bulging disc, which are common, will not improve a person with facet arthritis, a compression fracture or a ligamental injury). Operating on a herniated disc which is causing severe nerve root compression and has failed months of conservative therapy can be helpful. A good orthopedic surgeon will spend a lot of time talking patients out of having surgery and will make sure the diagnosis is correct before surgery. Even then, there are admittedly no guarantees. I’m sure if you’re honest you will admit you have some patients who do not respond to accupuncture.

        Your point number 2 is a medical error. Nothing to do with SBM.

        Point number three – bedrest for back pain has not been advised for decades. There are several possibilities for the patient who was bedridden for two years:
        1) She received the wrong advice or her providers truly did not listen to her, again a medical error and poor care 2) She received the right advice but chose not to follow it. 3) She misunderstood the advice. My experience has been that what the patient hears and what the patient is told are two separate things. There’s now a push in medicine to make sure that the patient can repeat the advice they were given in recognition of this fact. Did you obtain her records and verify that she was told to remain in bed? I would bet she was not.

        Science avoids using supernatural explanations for natural phenomena. For most of human history this was not the case. People afflicted with Huntington’s chorea were burned as witches and people with seizures were regarded as being possessed. Epidemics and disasters were attributed to deities – an example is the plagues of Egypt described in the Bible. Even recently some prominent fundamentalist preachers attributed Hurricane Katrina to the sins of the people in New Orleans. Thank goodness most of us are beyond that.

        I think you have a poor understanding of the scientific method.

        1. Dave you have just given me a few clues as to your misunderstanding.
          The reason back pain fails at all is that it is not needed. Back pain does requires therapy in the form of myofasical release therapy with hands-on and with needles. The reason back surgery is so successful is that it is a sham and not needed. Back pain will go away all by itself or with a little or a lot to therapy. The surgeons knife just stirs ups the healing process at a greater expense and danger. A lot of the back pain patient I have seen who had surgery and got will tell me that the pain post surgery was the same or worse and time … mother time was an integral part of healing. So yes … most 80-90% of back surgeries are unnecessary!

          Dang it … you guys are focused on Acupuncture like it is an aspirin. NO
          !!! It is a part of therapy. It is not about magic points or hocus pocus. I can link my description here if you like. Therapy in a sense should never fail, patients may not get completely pain free and mobility to return but that is better than surgical failures.

          You can’t use humans as objects in a scientific model; that is truly unethical. These models are a way to prove to a group of people who sanction payment for services as in commerce.

          And wait a minute are you saying that science can save us from ourselves? We can’t even agree on Acupuncture! Are you saying science is perfect? Please link me to the most perfect study you have read and agreed with without flaws.

          I think you’re confusing human advancements to Science, but it is technology that is the real reason.

          Stupid beliefs based on science, wealth and power plus a the willingness to allow some to suffer and or die is what caused the genocides of the kkk, holocaust or slavery.

          “In your quest to find the evidence you believe to be perfect, you are willing to ignore what you believe.” ? remember the author.

      3. WilliamLawrenceUtridge says:

        So Stephen, your reaction to scientific medicine failing to justify your preferred form of quackery is to substitute patient satisfaction surveys? How do you gather them from dead patients? Basically what you’re saying is “as long as the patient is happy, the intervention is effective”. What about when the intervention is morphine? I bet you’d get a lot of satisfied addicts.

        Observation is a necessary part of the scientific method. My observation is that there are too many failed back surgeries

        Yes, I agree – back surgery is an ineffective treatment for back pain. But so what? This is a false dilemma – it’s not “either surgery works, or acupuncture works”. Surgery is mostly not a valid treatment for back pain. Neither is acupuncture.

        I have a case where the surgeon did not read the chart for the chief complaint and only looked at the MRI and “fixed the wrong side.

        How is this anything except an indictment of that surgeon? How does this justify acupuncture? Wouldn’t the lesson to learn be ensure you’re operating on the correct side? How is this relevant to acupuncture?

        A patient’s death is more humane than to cripple them for decades.

        So, if you accidentally puncture a patient’s lung, is your next act to slit their throat?

        My simplistic logical care was able to get her out of bed and active again

        If her problem was back pain, that’s standard of care, not some sort of magic on your part.

        God in not part of this scientific method. Supplements that actually do nothing except by time taking advantage of nature’s Innate healing is a multibillion dollar a year industry.

        Both true, both irrelevant.

        The beauty of Needle therapy is that it is safe so one can actually use the needles as a tool to probe and find the problem tissues. Sort of like a multipurpose-tool!!

        Again, Kim Ribble-Orr. Google her. Also, have you seen Edzard Ernst’s systematic review of acupuncture adverse events? Acupuncture is generally safe, but not always – even for experienced practitioners. Maybe dial back the arrogance a bit?

  29. MadisonMD says:

    What’s the deal with SSR hijacking old threads to make asinine arguments about how acupuncture is outside the bounds of scientific inquiry?

    1. windriven says:

      Madison, These vermin use old threads as marketing tools for their twisted, exploitive ideologies hoping that thread fatigue or closing of comments will leave them the unanswered last word.

    2. No acupuncture in not outside the bounds as long as the definitions are clarified and the studies are modified to fit what acupuncture is really doing.

      1. Just saying you don’t believe, comprehend or you can’t find the evidence is not scientific. The journey for the truth is ongoing and never should end. unless someone has an agenda to promote.

        1. weing says:

          “The journey for the truth is ongoing and never should end. unless someone has an agenda to promote.”

          It sounds to me like your journey has ended.

        2. windriven says:

          “The journey for the truth is ongoing and should never end.”

          Yes, but the search for the untruth – at least for particular untruths – does end. Astrology is horsehockey. It is untruth. There is no more reason to reason to explore astrology. Chiropractic subluxation is horsehockey. It is untruth. There is no more reason to explore chiropractic subluxation. Acupuncture is horsehockey. It is untruth. There is no more reason to explore acupuncture.

          You can whine about aunt Myrtle and how acupuncture changed her from shriveled husk to Olympic triathelete. We doubt that it is true and are certain that if it is, acupuncture is not the cause.

          You have only the delusional words of a true believer. You have no evidence, no prior plausibility, no coherent theory, no anything. Your delusions would simply be pathetic if it weren’t for the vulnerable on whom you prey.

          1. I’m here hoping someone can help alter the course of modern medicine so we can discover the truth about needles! This is just the beginning of this journey.

            There is some true to hands-on therapy and faith healing. There is some truth to acupuncture and it is what the needles do to the tissues. Yes some of the didactics of acupuncture is a way the ancients concreted the concepts. They had to try to explain what they observed consistently and reproducible effects which is actually based on the scientific model. They wrapped the science within an artistic natural package.

            It is not very scientific to toss out an entire discipline just because of a few mis-concepts. A real scientist would want to search all the pieces of the puzzle and try to modify old set stale patterns of thought to try to connect the new data dots.

            Oh yes I’m a true believer, it would be folly to deny what you have witness for 15 yrs. NOT perfect but will help a few millions folks who are suffering in pain.

            Are you saying that you do not what these sufferers to try myofascial release with hands-on and needles? You would rather sacrifice their well being just so you can be correct in your assertion?

            If YOU care not to go on the journey, then get out of the way for the sake of the suffering! There are already tears-of-pain on your hands … please let not get blood on them.

            1. weing says:

              “I’m here hoping someone can help alter the course of modern medicine so we can discover the truth about needles!”
              But, but. You’ve already discovered the truth about needles. What else could there be?

            2. Harriet Hall says:

              “it would be folly to deny what you have witness for 15 yrs”
              19th century doctors thought they had witnessed therapeutic effects from bloodletting for longer than that before bloodletting was shown to do more harm than good. Was it folly for them to give up bloodletting? Is it folly for a theater-goer to deny what they witnessed: that the magician sawed a woman in half?

              I submit that it is folly to think that you have some superior wisdom that exempts you from following the evidence wherever it leads. The evidence adds up to one conclusion: acupuncture is a theatrical placebo.

            3. WilliamLawrenceUtridge says:

              There is definitely symptom relief in witch doctors, acupuncture and related pseudoscientific rituals of healing. That doesn’t mean there is any objective improvement, and it doesn’t mean the person got better because of the treatment. Not to mention, how is acupuncture superior to a $0.03 aspirin pill?

              It is not very scientific to toss out an entire discipline just because of a few mis-concepts. A real scientist would want to search all the pieces of the puzzle and try to modify old set stale patterns of thought to try to connect the new data dots.

              That’s rather rich, since that’s what acupuncture research has been doing – determining which factors matter, and which don’t. What doesn’t matter – needle location, skin penetration, using a needle versus a toothpick. What does matter – an enthusiastic and friendly practitioner.

              What “mis-concepts” are being missed by the scientific research? And how is your dogmatic “I don’t care what the science says” say about you? Why bother even pretending the science matters when it’s very clear to you that the science only matters if it confirms what you already know?

        3. WilliamLawrenceUtridge says:

          unless someone has an agenda to promote.

          What, an agenda like trying to preserve a medical practice in the face of contradictory evidence, or trying to discount scientific research in order to maintain a belief that one is a magical healer superior to his peers?

      2. windriven says:

        Rodrigues, you are a parasite. You deal in illusion, fear and superstition. You use the word science as if you understand anything about it. The word on your tongue is like a prostitute speaking of love.

        And once again you demonstrate just how brimming full of sh*t you are when you say. “[Y]ou can’t find the evidence is not scientific…” Furnish the evidence then, Rodrigues. Not your little anecdotes. Actual scientific evidence. You claim to know something about science so this should be easy for you. We’ve looked for evidence and found nothing. Step up to the plate, scienceman and wow us with your prowess.

        1. MadisonMD says:

          He clearly does not understand the limitations of anecdotal evidence, nor how systematic biases should be eliminated in any experiment. You are cannot possibly hope to get a reasonable response here, windriven.

          1. windriven says:

            No, you are, of course, correct. It drives me to my limits when these vacuous dolts mouth sciency locutions in an effort to advance the cause of medical quackery. It is nearly impossible for me to believe they are that ill-educated and shallow of thought. And that leaves only that they pursue quackery with malice and forethought. Either way it is inexcusable.

            1. Dave says:

              In this case I believe it’s ignorance. To equate science with the KKK or the holocaust speaks for itself.

      3. WilliamLawrenceUtridge says:

        What’s your definition that will lead to superior scientific studies? How is it different from extant definitions? Can you name even one study that used an inappropriate definition, according to you anyway? What if one of the authors is a licensed acupuncturist?

        Do you know what the “no true Scotsman” argument is?

    1. WilliamLawrenceUtridge says:

      Yes, one can always link to a multitude of raw sources. Which is the best and most convincing? Which is a randomized, controlled trial? Do you really expect us to go through entire books to find faults with each one? Why not link to the best scientific evidence for acupuncture and explain how they got it right? Or link to a negative study and explain how they got it wrong?

      Is it because you are scientifically illiterate?

  30. MadisonMD says:

    Madison, These vermin use old threads as marketing tools for their twisted, exploitive ideologies hoping that thread fatigue or closing of comments will leave them the unanswered last word.

    Looks to be exactly SSR’s game. He just posted a link from “medicalacupuncture.org”

  31. Please guys link me to the best study “whatever that might be” that convince you of a med, product, device or service. Show me what I seen not to able to comprehend.

    1. MadisonMD says:

      SSR: Since you seem determined to talk about acupuncture on a chiropractic education thread, why don’t you link to the single best study that will convincingly prove to us that acupuncture does work. Please provide a pubmed link to a single primary research article (analysis/meta-analysis).

      You will get a lot further in a science blog with a pubmed link rather than with specious arguments involving your personal anecdotes, nazi’s and KKK, links to youtube videos and acupuncture websites. Data talks at SBM. Everything else you are putting up is worthless blather.

  32. windriven says:

    Not unexpectedly, your very question betrays your ignorance. But let’s wave that aside and do a very, very easy one from WHO. Here is a link to a paper on smallpox epidemiology. Read it carefully. A disease that claimed as many as 20% of its victims (same reference) was eradicated from the face of the earth. Not by chiropractic. Not by acupuncture. Not by homeopathy. By science based medicine.

    Your lack of comprehension is clearly willful because no living being could be as obtuse as you pretend. Behold the panoply of medical interventions and the sweeping improvements they’ve made to the human condition. And then cast your gaze on quackery and its pathetic claims of one-off victories. Auntie Jane feels better after needle twirling or neck twisting or praying to Vishnu.

    Pubmed is littered with studies supporting untold numbers of interventions complete with measurable outcomes. Pick your condition and get to work. You will find not only evidence of the great victories but of failures both spectacular and mundane. This is science. Hypotheses, experiments, evidence, analysis, criticism, correction, painstakingly teasing the needles of truth from the haystacks of noise.

    Scammery and quackery on the other hand are not self-reflective, not self-critical, not self-correcting. They offer no data, only anecdotes. They dodge the light of investigation like cockroaches. They are, to steal a brilliant phrase, theatrical placebos* twirled in the hands confidence men who prey upon the fears of the vulnerable.

    *kudos to Dr. Hall for that locution

    1. Harriet Hall says:

      I didn’t originate the phrase. David Colquhoun and Steven Novella did. See http://www.sciencebasedmedicine.org/acupuncture-doesnt-work/

  33. Acupuncture is part truth and part philosophy. The truth part is inherent in what the needles do in the flesh which is a way of igniting healing. So is massage and all hands-on disciplines such as Chiropractic or Active Release or myofascial release therapy. There is even a parallel discipline called Travell/Simons trigger point injections.

    They all accomplish the same but use a different tool to ignite healing by activating the repair cascade. In acupuncture it is a needle, in hands-on it is hands and leverage, in Travell/Simons it’s a hypodermic needle. The reason we need these tools is because of damaged muscles and the secondary dysfunctions. These damaged muscle fibers are called Trigger points. TPs can only be manually treated with an injury or reinjury, ergo the need for these tools.

    Science is not flawed but the way you guys have redefined science and interpreting the data is flawed and unethical. Especially if someone reads your blog and decides that Acupuncture does not work and suffer without it. That is a false statement because Acupuncture and Chiropractic therapy are highly effective in quite a large number of patients.

    Science is not static so what we consider complete today will in a few yrs be erroneous. The studies you guys refer to have ended and so are the conclusion associated with that particular study. What if the studies when on for a longer period, the results and conclusions would be different.

    Science and data are not 100% exact like the number 1, it’s more like the number “pi” there are always errors and imperfections with inanimate objects and … wow … with humans there is no exactness.

    The quest you guys seem to be on is justification for what should be covered in health care. This commercialization of science is not science but pseudoscience.

    If you would like more info on TPs, Myofascial tissues pain and dysfunction, which is rampant in society, and how to treat it, please ask. Without this knowledge you are at a disadvantage of comprehension, not speaking it’s language.

  34. MadisonMD says:

    SSR:
    Again, you are validating the characterization ‘vermin.’ This is a ScienceBasedMedicine Blog. If you wish to drone on and on about your personal philosophy, please take it to Philosophy-Based Medicine. If you want to talk about science, the topic of this blog, post the pubmed link requested by me and WLU.

    In short: put up or check out.

  35. Wait, a good scientist will ask questions and not hide behind the science. You need to do the necessary leg work to clarify all this data. If you can find it in Pubmed it will be invalid, besides they would not published this kind of study!!!

    Are you being paid my big pharma, insurance companies or the AMA?
    Are you trying to put a personal or commercial value on these therapies?
    Are you guys peeved at the ACA? So you how think you have to pay for someone else “foofoo” medical services? Are you guys Government haters?
    Are you are trying to dictate what care patients have access to and thus perpetuating the present broken healthcare system?
    Are you trying to be paternalistic too and isolating patients for valid viable alternative choices.
    Ah …you are trying to limit freedom of choice! Let folks make the best choice for themselves without you poking your logic into their lives.

    This group is all about having stroking each others tattered egos. You don’t care about the asking the correct investigative or probing questions. I truly do not think your guys are interested in patients quality of life.

    When you guys and girls are ready to get your heads out of your stratospheres, read the suggested Authors, I suggested and get out in front and stop following the leaders.

    1. windriven says:

      The science is settled, dumb ass. That is what we have been saying. Go to PubMed, read the acupuncture posts here, whatever. But it won’t make a difference in what passes for your mind. Because while you use the words science and logic and sense, you are driven only by the fantasies in your head. For you this is metaphysics not science. Belief trumps proof. NCCAM has spent a fortune studying this crap with little to show for beyond a stack of cancelled checks.

      If you have questions, formulate them carefully and ask them one at a time. Your technique of blowing a fog of nonsense and expecting a reasoned response is as irritating as it is self-defeating. I, for one, am sick of your stream of consciousness whining. You remind me of a dull 5 year old asking, ‘why is there air?’

      Get serious or get lost.

    2. MadisonMD says:

      Wait, a good scientist will ask questions and not hide behind the science.

      I did ask a question. Where is your citation? SSR, you seem to be off your Thorazine. You clearly are in the wrong place.

  36. Scientist error;
    by using old stale data and not asking the proper questions.
    when they blame, slander and are lazy with methodology.
    when they outright refute real life and real-time outcomes.
    deny or disrespect the exact place where evidence comes from the front lines.
    do not believe the oral testimony of patients.
    relied heavily on numbers, charts and tables.
    forget science is not exact and incomplete.
    Hide behind the word “Science” and ignore the flaws.
    In the quest to find the evidence you believe to be perfect, you are willing to ignore what you believe.
    engage in magical thinking
    if you chose to ignore the word of sincere reporters.
    selfish that is bias.
    when they promote science over clinical data and experience.
    stubborn to their beliefs, despite evidence, deny valid therapy, engage in personal attacks to aggrandize of themselves that is a zealot.
    are too radical and sacrifice the suffering which can make them despots.

    I will be here until the false and misleading statements about acupuncture are clarified or given the proper caveats.

    1. windriven says:

      “I will be here until the false and misleading statements about acupuncture are clarified or given the proper caveats.”

      Please do stay around, Rodrigues. You are our lodestone for all things ignorant. You celebrate anecdote and dismiss carefully collected data as “numbers, charts and tables” as if your dismissal makes them somehow less powerful. You mouth words without any comprehension of what they actually mean.

      When visitors read the blogs and peruse the comments, there you’ll be, the wet, stinky cow flop in the middle of the floor, emitting a miasma of indistinct, Ill-conceived, delusional nonsense in perfect counterpoint to the well-reasoned arguments of Gorski, et. al. In this perhaps you have found your true mission in life, the perfect embodiment of the gullible CAMisto, desperate to be taken seriously by a world you don’t remotely understand. I’m even going to lighten up on you myself. I first thought that you were a pure charlatan, preying coldly on the frightened and the vulnerable. Now I’ve come to understand that you are simply a moron and it is unseemly to taunt and torment the unarmed.

      1. I expected that from a harden despot by definition, Thank you for proofing your position in mankind.

        If ever you want to be inspired by any insight into the world of alternatives with needles, myofascial release therapy with hands-on and with needles as per Travell/Simons, Gunn, Hackett, Rachlin, feel free to ask.

        1. windriven says:

          “I expected that from a harden despot by definition”

          From Merriam-Webster, despot:

          “: a ruler who has total power and who often uses that power in cruel and unfair ways

          : a person who has a lot of power over other people”

          Hmmm, I don’t have that kind of power within my own business*much less as a lowly commenter here in the SBM peanut gallery. You must have been referring to Dr. Gorski but, you know, I’ve never seen him use his power “in cruel and unfair ways.” So maybe not.

          *i own a couple of small medical manufacturing companies. I do not think I am being delusional when I tell you that my employees would characterize me as rather more benevolent than the average despot.

    2. Harriet Hall says:

      “do not believe the oral testimony of patients.”

      You don’t get it. We do believe the patients when they say they feel better. The thing is, we also believe the patients in the control group when just as many of them say they feel better. You are the one who is engaging in magical thinking and refusing to see the obvious: acupuncture is a theatrical placebo.

      1. I expect this from a zealot by definition. If you refuse to accept all types of data even that of a victim of traditional medicine who has benefited from myofascial release therapy with needles and hands-on, you are not a scientist but a zealot choosing who to believe based on a set stubborn ideology.

        All data should be considered in the study of medicine. Especially when people and souls are involved.

        1. Harriet Hall says:

          Ha, ha, ha! You, sir, are the zealot by definition. You illustrate once more that you don’t have enough understanding of science to be discussing it on this forum. You can’t even stick to one subject: you switch from acupuncture to myofascial release. And now you bring in “souls.” Citation needed. Thanks for the comic relief!

        2. MadisonMD says:

          SSR:

          All data should be considered in the study of medicine.

          So if a surgeon posts here that patients have been relieved of back pain by laminectomy, you would like us to accept that as proof of the effectiveness of surgery?

  37. Dave says:

    In a final attempt to illustrate to SR what we are talking about I would like to report today’s New England Journal of Medicine lead article, which demonstrates the point.
    The background on the study is that a previous randomized trial showed that arthroscopic partial meniscectomy combined with physical therapy provides no better relief of symptoms than physical therapy alone in patients with a meniscal tear and knee osteoarthritis. The current study is a multicenter, randomized, double-blind, sham-controlled trial to assess the efficacy of arthroscopic partial meniscectomy in patients who have a degenerative tear of the medial meniscus without knee osteoarthritis.The study was done at five orthopedic clinics in Finland during the period from December 2007 through January 2013. Some patients had an arthroscopic meniscectomy. For the sham surgery, a standard arthroscopic partial meniscectomy was simulated. To mimic the sensations and sounds of a true arthroscopic partial meniscectomy, the surgeon asked for all instruments, manipulated the knee as if an arthroscopic partial meniscectomy was being performed, pushed a mechanized shaver (without the blade) firmly against the patella (outside the knee), and used suction. The patient was also kept in the operating room for the amount of time required to perform an actual arthroscopic partial meniscectomy.

    The following is a description of the outcomes measure:
    “Outcome Measures

    Initially, our two primary outcomes were knee pain after exercise (during the preceding week) and the Lysholm knee score at 12 months after surgery. Knee pain was assessed on an 11-point scale ranging from 0 (no pain) to 10 (extreme pain). The Lysholm knee score is a validated,14 condition-specific outcome measure.15 After the Western Ontario Meniscal Evaluation Tool (WOMET),16 a meniscus-specific health-related quality-of-life instrument, was validated for patients with a degenerative meniscal tear,17 this measure was added as our third primary outcome (before any data analysis). The Lysholm and WOMET scores each range from 0 to 100, with 0 indicating the most severe symptoms and 100 an absence of symptoms. Secondary outcomes included the score for knee pain after exercise and the Lysholm and WOMET score measured at 2 and 6 months after surgery; knee pain at rest, measured at 12 months; and the score on 15D, a generic health-related quality-of-life instrument made up of 15 dimensions and scored on a scale of 0 (death) to 1 (full health), also measured at 12 months”

    The results of the study were that the Lysholm and WOMET scores for the arthroscopic surgery group improved considerably, by 21.7 points for the Lysholm score and 24.6 for the WOMET score. However, in the sham surgery group the Lysholm score improved by 23.3 and the WOMET score by 27.1.

    The conclusion from the abstract:
    “In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure. (Funded by the Sigrid Juselius Foundation and others; ClinicalTrials.gov number, NCT00549172.)”

    SR, similar studies on accupuncture vs sham accupuncture have yielded similar results. Several posters have asked you to supply evidence that your treatment has superior outcomes to sham procedures. So far you have not done so. We have no doubt that some of your patients improve, as did the arthroscopic surgery patients in the study I’m reporting. The question is whether your intervention is the cause of their improvement.

    Also note that the current study in the NEJM flies in the face of the conspiracy theorists who feel the medical journals are nothing but a shill for the medical-industrial complex.

    1. windriven says:

      Nicely said, Dave. But I think the difficulty is that Rodrigues simply does not recognize the differences between RCTs and personal experiences. In his mind these are both truths, perhaps different in aspect but certainly not in kind. I find it both depressing and deeply disturbing.

    2. MadisonMD says:

      Dave and windriven:
      A prediction. He will miss the whole point that you can discover that the intervention didn’t work by using a control.

      In the warped SSR version of the universe, this NEJM study shows that sham surgery works. Follow me here: the sham surgery is ‘just like’ needles (actually a poorer substitute). Therefore the only possible conclusion in SSR universe is that needles work.

      Now cue the music, lights and welcome the one and only SSR for comedy hour. Heeeree’s Stephen….

    3. Good article for the design, implementation and conclusions … Excellent example. This type of study confirmes why I prefer not to give my blessing on these procedures.( if I have any say.) If a patient ask for my opinion, I will sit down with them, draw out my concepts on a sheet of paper, give my ideas and conclusions.

      I see pain and dysfunction in 2 languages, Traditional and Nontraditional or Myofascially.
      Medical school taught me the standard language of medicine, science and these studies.

      Then I stumbled into the world of Travell/Simons, C. Chan Gunn, Edward Rachlin and Stuart Hackett. It’s truly a way to view the human body in a parallel fashion. You see the body from the outside in and not from skeletal level out. This new paradigm has helped many of my patients who have failed traditional medicine and surgeries. So you might guess I’m a little hesitant to suggest many traditional orthopedic surgeries as they relate to pain. There are some awesome things othopods are doing in their field but there are some awful ones too. The awful ones are based one a few key elements ignored in the muscle bundle called trigger points.

      These authors focus treatment on the the detrimental effects of TPs which are embedded in muscles. TPs cause the muscles to act erratically, pull and contract out of sync, spasm indefinitely and falter. The worse is when the TP load reaches a certain level the muscle will auto-dysregulated and lock up to the point that it no longer functions as a proper muscle. These ongoing contractions and dysregulation alters cellular and the subcellular milieu and some have found uncharacteristic and detrimental microscopic changes.

      So in the world of chronic pain and myofascial dysfunction (MFD) here are a few new truths;
      >Pain is not emanating from where you think it is. See the referred pain patterns of MFD caused by TPs above or below a joint segment.
      >A knee is not just the knee joint proper, but the unit from the hip to the foot. It is a shock absorbing unit and pain can project into knee without any internal knee structure derangements.
      >Supposedly joint structures do not eliminate pain signals as we think. Why do patients still have pain in the knee post-knee replacement or phantom pain.
      >Physical therapy is not just the a formal prescribed clinic experience, but can accomplished just by doing chores around the house. De Facto PT
      >A meniscus it just a part of the knee and as we just stated do not have pain fibers (as we think). Since the meniscus do not emanate pain they should be choice #1 in pain of the knee. Surely they should not be removed unless completely demolished and effecting ROM.
      >Same for cartilage or we all would be in pain if we jumped up and down compressing these tissues. And remember those xrays of people with humeral head ulcerations, they have minimal or no pain.
      >What we see on xray is static and not the dynamic elements of the body. Almost like forensic study of dead or static structures. You all have heard of pain in the lower back with normal MRIs, or abn MRIs in patient with no pain.
      >Any injury can ignite healing, be it by a surgical blade, arthroscope, hypodermic needle or cold laser, your intent is irrelevant.
      >Most patients have multiple factors contributing to an illness, what were the exclusions.
      >A diagnosis is a guess and has to be based on the history and physical exam then confirmed or refuted by diagnostic testing.
      >Auto healing is an innate ability and can not be stopped. It can be stalled or slowed.
      >All patients have a different pain tolerances and perception levels depending on the environment, stress level and even genetic.
      >The pain of a knee injury is not always the same throughout the week because pain is variable.
      >In the study, I’m sure they did not perform an exclusionary PE of muscle, ligament and tendon to rule out myofascial pain.

      See my dilemma??

      1. Harriet Hall says:

        Ha, ha, ha! You continue to provide comic relief.
        Went right over your head.
        You were given an example of how a procedure can appear to be effective, but controlled testing shows it to be no more effective than placebo. Instead of realizing the analogies with acupuncture, all you heard was reinforcement of your belief that “surgery doesn’t work” because pain blah blah blah.

        Acupuncture appears to work, and you have seen many examples of patients who said they felt better, but controlled testing has shown that it is no more effective than placebo. No matter how many times you have seen it “work,” your personal experience is biased: you have not done controlled observations.

        Here is your homework assignment: read http://www.sciencebasedmedicine.org/why-we-need-science-i-saw-it-with-my-own-eyes-is-not-enough/ Then come back and tell us why you feel it doesn’t apply to you. We can always enjoy another laugh at your expense.

        1. YES, We are trying to examine the same things and I agree with these!
          The disease may have run its natural course.
          Many diseases are cyclical.
          We are all suggestible.
          There may have been two treatments and the wrong one got the credit.
          The original diagnosis or prognosis may have been incorrect.
          Temporary mood improvement can be confused with cure.
          Psychological needs can affect our behavior and our perceptions.
          We confuse correlation with causation.

          Plus the the science method has inherent problems:
          regression to the mean.
          The peer review process is flawed.
          Financial gains.
          Humans hate being wrong, so selective reporting, significance chasing and personal bias.
          Poorly designed studies.
          And again the science methods are vital with unnatural therapies but once you use humans with our fickle nature especially with people are under duress as with pain and miserable, expect lots of variations and errors.

          The raw science methods are not very practical or logical in the office setting whereas the trial and error or try and see methods are the standard.

          “The first principle is that you must not fool yourself–and you are the easiest person to fool.”sbm
          Try to understand the journey and not fool yourselves just because I’m who I am. (little ole me)

          I just want to add in a few truths I have uncovered based on what I have learned from my authors and Myofasical pain and dysfunction. Gunn is the only one available on the web: http://youtu.be/Qf_qwzPT7qo

          >Pain has to be defined and elucidated before you can begin to treat it.
          >The so classification of the pain be it “electrical pain” or “in the bone”’ has little value on what is causing
          >MF pain and dysfunction must be treated to elucidate the truth, without therapy the provider is negligent in his/her care.
          >Come on guys please look up the healing cascade http://en.wikipedia.org/wiki/Wound_healing, which is how the body heals itself, all by it’s design. Haven’t you all heard that cells are in a constant cycle of turnover and this turnover can speed up or slow down?? Igniting the healing cascade can increase the rate of turnover activity be it with a hard gym workout or a hammer.
          >Myofascial pain can mimic intra articular problems, there was no info on this exclusions. A lot of time with MFD will be “cured/treated” with just time, heat and stretching.
          >So the If you would even try to understand Myofascial pain and dysfunction you would be able to comprehend how pain can masquerade as an entirely different pain syndrome. MF pain is not where it’s appears and the only way to find it is with trials, in-office needling and testing to determine how the patient responds in the office, real time.

          That arthroscopic study was a futile exercise, my authors, would not have sanctioned or designed. A meniscus does not cause disabling pain and what it looks like has no bearing on pain and disability per se. What it looks like is only an objective data point via an MRI, X-RAY or Arthroscope. Carrying no more weight than my thumb!

  38. windriven says:

    @MadisonMD

    I’m still laughing as I type this, not because I think you’re wrong, but because I’m sure you’re right! The realization that he sees the sham surgery as a poor substitute for needles is hysterical.

    1. MadisonMD says:

      Did you see it then? It was a bit buried in all the gobbledygook:

      >Any injury can ignite healing, be it by a surgical blade, arthroscope, hypodermic needle or cold laser, your intent is irrelevant.

      That’s all for today folks. Tune in tomorrow.

  39. BMBS says:

    There are a number of different ways to treat these conditions, I think it’s worth looking at all options.

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