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The DC as PCP?

Subluxation-free Chiropractic?

The long-simmering internecine wars among various factions of chiropractic recently reached a full boil when the Council on Chiropractic Education (CCE) had the audacity to eliminate the word “subluxation” from its draft 2012 “Standards for Doctor of Chiropractic Programs.” The CCE is the official U.S. Department of Education-approved accreditation agency for chiropractic colleges. It intends to adopt the revised Standards in January 2011and asked for comment from those affected.

“Totally unacceptable,” is the response of James Edwards, DC, in a recent article in Dynamic Chiropractic entitled “What Is the CCE Trying to Pull?

Perhaps taking up the spirit of this election season, Edwards defines the problem in terms of conservative vs. liberal ideologies: “After beating back and defeating the ridiculous ‘subluxation only, no diagnosis’ position of the extreme right-wing minority of the profession, we are now faced with the equally unacceptable ‘ivory tower’ position of the extreme left-wing minority of the profession.” Later in the article he refers to the proponents as the “left-wing fringe.”

Edwards is further exercised by the CCE’s plans to remove the phrase “without the use of drugs or surgery” from its description of chiropractic practice. As well, the CCE proposes, somewhat cryptically, to accredit any program which it deems to be “equivalent” to the D.C. degree program.

The proposed changes prompted the International Chiropractic Pediatric Association to send out an “URGENT! Action Needed!” e-mail requesting that members fax in objections because “the CCE has a few proposals that will drastically affect the future of chiropractic.”

Gerald Clum, DC, in a memo expressing concern from his faculty position at Life Chiropractic College West, opined that this meant the CCE might approve a “Doctor of Chiropractic Medicine” degree “or any other creative reconfiguration of a chiropractic curriculum.” Clum also noted the removal of references to the “Purpose of Chiropractic Education” from the Standards, with no replacement language in the new version. The following language was deleted:

The application of science in chiropractic concerns itself with the relationship between structure, primarily the spine, and function, primarily coordinated by the nervous system of the human body, as that relationship may affect the restoration and preservation of health.

Readers familiar with chiropractic will recognize this as a reference to the vertebral subluxation complex.

Finally, Clum noted “the change in the definition of chiropractic primary care physician [by the proposed Standards] removes any definitional elements that would cause the statement to be unique to the practice of chiropractic. The definition as proposed would apply to any primary care medical doctor, nurse practitioner, physicians assistant, etc.”

Parker College of Chiropractic officially expressed its concern in the on-line publication ChiroAccess, although it took a more subdued approach, saying only that it would like “to see additional clarity or further expansion” of the changes.

Another change is escalation of the required GPA for admission to chiropractic colleges from a 2.5 to 3.0. Parker asked for a more gradual change “because a drastic change could negatively impact admissions and institutions need the opportunity to mitigate this change through other means.”

The “Certified Advance Practice Chiropractic Physician”

So, What Is the CCE Trying to Pull in sanitizing its accreditation requirements so they appear less, well, “chiropractic?”

I don’t know, but it may have something to do with a prototype of the future chiropractor set forth in a law passed in New Mexico last year.

You may recall that New Mexico is one of the few states to allow anyone to practice medicine despite having no license, no education and no training. So it is no surprise that New Mexico is the first state to create a new iteration of chiropractic known as “Chiropractic Advanced Practice.”

The New Mexico Legislature created this new class but left the details to the NM State Board of Chiropractic Practice. The Board, while retaining the subluxation-based definition of chiropractic, added a category of “certified advanced practice chiropractic physician,” defined as an “advanced practice chiropractor who shall have prescriptive authority for therapeutic and diagnostic purposes.”

All you have to do to register as an advance practice chiropractor is (1) fill out an application, (2) complete 90 “clinical and didactic” hours of education provided by an approved institution, and (3) pass a competency exam. In other words, take the equivalent of a little over two standard work weeks of instruction and a test and — voila! — you’re “certified” for “advanced practice.”

The rules prescribe a formulary that consists of “those substances that are natural or naturally derived.” The initial formulary and any changes to it must be approved by three boards: medical, pharmacy and chiropractic. This smells like a compromise on the part of medicine and pharmacy, and the smell is not a pleasant one.

SBM contributor Scott Gavura, BScPhm, MBA, RPh, provided some insight into the formulary as prescribed by rule in NM. It includes estradiol, progesterone, and testosterone, all of which are used as hormone replacements, as well as desiccated thyroid, which alt med practitioners believe is effective for thyroid replacement, although it is rarely used nor is it recommended by evidence-based guidelines. Also included are drugs widely disparaged for years by chiropractors: muscle relaxers and NSAIDs. There is also sarapin, a dubious treatment for neuropathic pain, and glutathione for inhalation, an alt-med treatment for lung disease. Of course, homeopathic preparations “requiring prescription” and “for injection” are included. And, even more inexplicably, caffeine for injections.

It sounds like the perfect formulary for increased chiropractor income.

The origin of the “certified advanced practice physician” requirements is explained in a press release put out by the National University of Health Sciences (NUHS), in Lombard, IL, and posted on ChiroAccess. (In addition to its DC program, NUHS offers degree programs in naturopathy, acupuncture and massage.)

As the press release explains:

The United States is experiencing a shortage of primary care family doctors. That’s why over the last 8-10 years, chiropractic associations in states with severe shortages of primary care physicians have sought to expand the scope of practice for chiropractic physicians… . By granting [chiropractors] the ability to prescribe select medications, specially trained and licensed DCs can help a significant number of patients who would otherwise be forced to seek simultaneous care from an already overburdened and limited pool of MDs in general practice.

Those state chiropractic associations! Always looking out for the best interests of patients and overburdened MDs.

Thus, the state associations contacted “experts at [NUHS]” and asked them to “assess what additional training would be necessary.” The experts decided on 90 hours in pharmacology “in addition to the prerequisite physiology and biochemistry courses already required by accredited chiropractic education programs.”

NUHS is, helpfully, offering these additional hours in New Mexico to those who want to become advanced practitioners. In addition to an instructor who has a Ph.D. in pharmacology and pharmocognosy, the NM students “are receiving training in injectible [sic] nutrients and drugs from Dr. Michael Taylor, a chiropractic physician who also holds a diplomate [sic] from the American Board of Chiropractic Internists.”

And what better way to beef up the ranks of family practice doctors, pediatricians and internists than with chiropractors wielding syringes full of “injectible nutrients?”

The E-Z Way to Primary Care Practice

But here is the really interesting part of the NM law: After December 31, 2012, the examination requirement can be met by “successfully complet[ing] a graduate degree in a chiropractic clinical practice specialty.” And where might one get this degree?

As it turns out, NUHS is also offering a “Master of Science degree (MS) – Advanced Clinical Practice” (or “MSACP”) which is “An Advanced Degree designed for the Chiropractic Profession” beginning in September, 2011. The only requirements  are a minimum 2.5 GPA in a ”first professional degree” program.

The MSACP program consists of weekend courses spanning two years, 18 in the classroom and 8 in “distance learning” format, plus one “case defense” and one “capstone defense” (whatever that is).

The program conveniently includes the 90 hours of pharmacology required by New Mexico and is presumably the origin of the chiropractic board’s decision to skip the exam if a chiropractor has the “advanced clinical practice” degree. Thus, if you take this course, you’re in, at least as far as New Mexico is concerned.

But chiropractors promoting this new degree obviously have bigger fish to fry. The NUHS course descriptions give a hint as to what those fish might be. Weekend and “distance learning” courses include clinical neurophysiology, clinical problem solving for the primary care physician, clinical neurology, advanced diagnostic imaging, psychological issues of illness, pediatrics, women’s and men’s health/geriatrics, inflammatory mechanisms, dietary prescription, and advanced clinical laboratory medicine.

Hmmm. Why would anyone go to this much trouble when he can just as easily qualify for NM’s “certified advanced practice chiropractic physician” registration by taking 90 hours of classes in pharmacology and a test? In fact, NUHS already incorporates this 90 hours into its regular D.C. program, so all those graduates would have to do to register is take the test.

Here’s why. As the NUHS press release continues:

Because of this growing interest (in expanding the scope of chiropractic practice) NUHS is also thinking about offering its MSACP (Master of Science in Advanced Chiropractic Practice) in New Mexico as well, and is strategizing how to deliver similar programs in other states in the future.

(Emphasis mine.) 

The press release ends with this sunny prediction by James Winterstein, president of NUHS:

Chiropractic physicians are already licensed as primary care doctors in most states … As health care policy-makers wrestle with the scarcity of general practice physicians, expanding the scope of chiropractic care to qualified chiropractic physicians makes good economic and strategic sense. New Mexico’s citizens will undoubtedly benefit from broadening health care delivery by chiropractic physicians, and we anticipate that more states will see the wisdom in this as well.

Let’s hope not.

The MSACP course descriptions illustrate just how far they would like to venture. All of the courses described below take place over one weekend. (All emphasis in quotations mine.)

Clinical Skills for the Primary Care Physician:

… present and demonstrate clinical skills including comprehensive history taking and regional physical examinations skills in the context of common and complex internal disorders. The student will be enabled to effectively integrate these skills and formulate an accurate differential diagnosis and integrative treatment approach.

Clinical Problem Solving for the Primary Care Physician:

The purpose of this distance learning course is to refine and expand upon clinical problem solving skills with an emphasis on internal medicine. The student will be able to effectively integrate patient history and physical examination findings into an accurate differential diagnosis with consideration of appropriate diagnostic testing.

And, I must comment, certainly there is no more effective way for the physician to learn patient history taking, physical examination, and differential diagnosis that watching these things on a computer screen.

Clinical Nutrition I – Inflammation Mechanisms and Dietary Prescription:

… a detailed understanding of the altered biochemistry that underlies the expression of most inflammatory related diseases. Current evidence-based nutritional literature will be presented as a foundation for the clinical application of appropriate dietary changes and key nutritional supplements.

Pediatrics:

… an overview of common pediatric disorders and effective methods for approaching evaluation and management of the pediatric patient. Well infant and child examinations will also be discussed and demonstrated. Students will gain an understanding of normal growth and development and discuss scheduled vaccinations and their associated risks and benefits.

Women’s & Men’s Health/Geriatrics:

… illustrates common and complex conditions impacting the health of women and men, including the geriatric population [including] pathophysiology, differential diagnosis and effective integrative and allopathic treatment strategies will be discussed.

So that’s it! They want to be real doctors who make “differential diagnoses” and “evaluate and manage the patient” and prescribe “dietary changes,” “nutritional supplements,” and “integrative treatment strategies.” Wait, no, that’s naturopathy. They want to be naturopathic doctors?

As it turns out, the American Chiropractic Association (ACA) has its own “Council on Diagnosis and Internal Disorders:”

… an educational Board that endorses and coordinates a post doctorate degree; Diplomate in Diagnosis and Internal Disorders (DABCI). Our Doctors are trained in the most advanced forms of modern medical diagnosis and natural medicine. Our Doctors diagnostic training far exceeds the current standards of health care practice utilizing many current and specialized diagnostics such as: blood chemistries, orthomolecular evaluation, electrocardiograms, vascular ultrasounds, lung function studies, bone density testing, hormonal evaluations, delayed food allergy testing, and much more. Treatments may include; nutritional recommendations, dietary modification, supplement recommendations, homeopathic and naturopathic remedies, natural hormone replacement, etc. Most conditions if diagnosed properly can be resolved naturally and our doctors and the most qualified to provide this service.

Training far exceeds the current standard? Most properly diagnosed conditions can be resolved naturally? Where do they get this stuff?

The ACA’s program, called “The Natural Approach to Family Medicine,” also takes place over a series of 26 weekend sessions (Saturday, 9AM-5 PM; Sunday, 8AM-Noon), although the student can take only one session per month to get credit. Some session titles: Diseases and Exam of the Pelvis & Associated Pathology; Urinary Disorders and Hair Biopsy Assessment; Malignant Diseases, AIDS, & their Management & Treatment; and Upper Gastrointestinal Disease.

So, in sum, chiropractic’s leading organizations — or, depending on your point of view, the pointy-headed, ivory-tower liberals — have seen the future of chiropractic and it is not chiropractors!

The International Chiropractors Association(ICA) is having none of it. Through an article in “Chiropractic Choice,” Stephen P. Welsh, DC, Fellow of the ICA, saw right through NUHS and its grandiose plans:

“A wolf in sheep’s clothing” is the phrase that comes to mind… . The arguments of the moment asserting needs due to provider distribution and availability and the extension of nutritional approaches into the arena of nutraceutical therapies are red herrings. The goal of the advocates of these changes is to practice primary care medicine, without fully qualifying at the appropriate standard to do so. It is disingenuous to assert that these changes are being made to address a sudden deficiency in providers in New Mexico or elsewhere or a spectacular new advantage to some form of nutritional therapy.

Couldn’t have said it better myself.

Posted in: Chiropractic, Legal

Leave a Comment (87) ↓

87 thoughts on “The DC as PCP?

  1. Mojo says:

    Many UK chiropractors don’t seem too happy with the GCC’s advice that “The chiropractic Vertebral Subluxation Complex…is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.” See Blue Wode’s posts here and here.

  2. daedalus2u says:

    Most [The only] conditions [our doctors can] if diagnosed [treat] properly can be [will] resolved naturally and our doctors and the most [are only] qualified to provide this [useless and deceptive] service.

    There, fixed that for you.

  3. daedalus2u says:

    Most [The only] conditions [our doctors can] if diagnosed [treat] properly can be [will] resolved naturally and our doctors and the most [are only] qualified to provide this [useless and deceptive] service.

    Sorry, HTML fail, fixed

  4. colli037 says:

    This appears to place them at even further risk for malpractice claims. Their continued push to become “primary care doctors” is going to result in a huge increase in claims against chiropractors.

    Unfortunately many patients will be harmed or die.

  5. If some of the standards for “training” reported here got any lower they would disappear altogether. I find it hard to understand why people interested in training like this don’t simply take that final step and start forging their credentials. Why take the time to pretend to learn anything?

  6. Jann Bellamy says:

    @colli037:

    Good point and one I had not thought about. And increased claims = increased premiums = need for more income = need to attract more patients.

  7. marcus welby says:

    It seems that chiropractic has always been troubled by the fact the entire field is a house of cards. For 115 years, they have not really advanced beyond a bundle of placebo treatments plus massive marketing effort, backed up by political pressure. Extraordinary efforts continue to try to prove some health benefits beyond the patient-practitioner encounter with no success. The subluxation concept has been incorporated into the definition of chiropractors in every state in the U.S. and there are chiropractic journals using the name “Journal of Subluxation Research” for example. Yet, the definition of a subluxation has never been a settled one, nor is there agreement among chiropractors that there is such a thing. The concept has no reproducibility and two chiropractors examining the same patient will not come up with the same diagnosis, nor can they tell whether the subluxations they diagnose have already been treated and “adjusted”.
    I suspect the profession is anxious about the trend toward only evidence-based and science-based treatments being reimbursed in an age of greater fiscal concern.
    In Florida, chiropractors allied with plaintiff lawyers prey on auto accident and slip and fall litigants who are conflicted on their desire to recover from compensatory musculoskeletal pain. This is a major source of income for chiropractors here.
    The desire to broaden their scope of practice to include prescribing and injections, (in some areas of the country, I think in California, spinal manipulation under anesthesia is a popular chiropractic procedure) is understandable, but not likely to be in the best interest of a healthy public.

  8. Dr Benway says:

    in California, spinal manipulation under anesthesia is a popular chiropractic procedure

    WHAT IS THIS I DON’T EVEN..

  9. Dawn says:

    @Dr Benway: MUA is quite the “up and coming” treatment here in New Jersey, too. Looking at videos of the procedure makes me sick to my stomach, and people AGREE to this!

    Not only is there the anesthesia risk, but the risk of major injury to the joint. I can’t remember HOW many times in nursing school we were warned about being extremely careful caring for a patient under general anesthesia, because of the muscle/tendon relaxation. And these chiros are rotating joints with merry abandon.

    I’m not saying MUA doesn’t have its purpose; certainly, for a joint dislocation it may need to be done.

  10. overshoot says:

    This appears to place them at even further risk for malpractice claims.

    That would be a first. The State Quackery Boards (e.g. Arizona’s State Board of Homeopathic Examiners) pretty much rubber-stamp anything one of their people do as being dead center in their standard of care, and you will absolutely never get another DC or ND to “whore [1]” for the plaintiff. The Code of Silence in the quackery community makes the Blue Wall look utterly transparent.

    In Arizona, for instance, a “homeopathic physician” actually killed a patient under surgery. No repercussions. Zip.

    [1] Term of art in personal injury law.

  11. BKsea says:

    And in other news, homeopaths have removed the law of similars from their standards. Well, we can wish can’t we?

  12. aaronupnorth says:

    Wow, what a rigorous curriculum they are proposing……puts my alma mater (Hollywood Upstairs Medical College) to shame!
    How altruistic of DC’s to offer to fill the PCP void.
    You know I’m an emerg doc but I have always had an interest in cardiac surgery, so maybe I could take a few weekend courses and make that switch too?
    Preposterous!
    Dr. J

  13. daijiyobu says:

    NUHS is on my radar because they have the newest naturopathy program in North America.

    Id est, science subset naturopathy.

    Fascinating.

    -r.c.

  14. nwtk2007 says:

    Although I don’t see chiro’s as PCP’s, orthopedists or surgeons either for that matter, I do find ammusment in some of the comments here.

    i.e. – Overshoot – “In Arizona, for instance, a “homeopathic physician” actually killed a patient under surgery. No repercussions. Zip.”

    I mean really, ‘killed”? How? Does it compare with the 500 or so “killed” everyday by medical mistakes? Just asking.

    And what is “under surgery”?

    Bizzarre.

  15. Joe says:

    @nwtk2007 wrote “Does it compare with the 500 or so “killed” everyday by medical mistakes? Just asking.”

    People under medical care are actually ill (as opposed to the worried-well, targeted by chiropractors), and many need heroic measures to save them. One must consider, and study, risk vs. benefit.

    More than that, you get the numbers relating to medical mistakes because physicians are studying how to minimize them. Chiros do no such thing. In fact, they deny the well-documented risk of neck-snapping, and ignore the fact that any “benefit” is unproven.

    Chiropractors are really not in a position to criticize the safety of medicine.

  16. nwtk2007 says:

    Once again, you paint an inaccurate picture of what a medical mistake is. But thats OK, those who die because of the “mistakes” made are still dead. I’m sure those who are “killed” by “mistake” would be dead soon anyway, despite the relative minor condition they are getting treatment for. (Of course, you could point out the one case previously discussed of an apparent stroke due to a CMT procedure, but it pales next to the 500 or so deaths every day due to medical mistakes.)

    Its clearly deliniated between mistakes and poor or difficult outcomes related to high risk cases. One other thing Joe, the concept of risk does not and shouldn’t include the risk of “mistakes” or “accidents”. Risk has to do with complications related to procedures, not mistakes made in the implementation of the procedure or treatment.

    Your response is nothing if not an out and out lie about what medical mistakes actually are. Risk or not, mistake or not, they are still errors and mistakes. Accidental killings if you will. Its not the heroic measure that is being referred to when medical mistakes are being addressed and you know this all too well.

    As always it is the pot here calling the kettle black. And as a chiropractor, I am very much in a position to criticize the safety of medicine, as are all doctors and patients in all areas of healthcare. In other words, everyone everywhere is in a position to criticize and should.

    You sometimes amaze me Joe with your elitist, “we are better than all others” attitude. Such is the basic problem with health care here in the states; the attitude that medical science can do no wrong, now being extrapolated to the insurance and pharmaceutical industry acting the same part and parcel of the big game which is, of course, to make lots and lots of money. Its always the bottom line don’t you think?

    Of course medical science makes every effort to minimize the problem as does chiropractic. I can’t speak for homeopathy. Of course, I have my doubts about a statement that a homeopath “killed” a patient while “under” surgery.

  17. Joe says:

    @nwtk2007

    Why don’t you start by providing us with the evidence that the chiro neck-snap is more effective than safer methods.

    Or else, provide us with the evidence that a chiro can cure critical, non self-limiting, illness.

    Of course, as you wrote “And as a chiropractor, I am very much in a position to criticize the safety of medicine …” is true. But, you cannot offer you trade as a reliable replacement. You mostly are not in a position to harm people because you mostly do nothing beneficial for them.

  18. nwtk2007 says:

    Interestingly enough, many of my patients transfer their care to me because of the medical practitioners failure to relieve them of their pain and get them better. They appreciate the meds and a few even receive some PT, but the depth of the care is scant at best. I request the records and see this over and over; poorly documented, inconsistent, ineffective care. In many cases just the addition of CMT (the proverbial neck snap)is all that is needed to get these patients moving in the right direction. It seems that many chiropractors offer a pretty reliable replacement for musculoskeletal conditions at the very least.

    You say we do nothing beneficial for them yet they express their relief, we document their progress in a quantified manner and return them to their regular daily lives. Not all chiropractors operate at this level of proficiency and effectiveness but many do.

    Of course, once again, you fail to see the point being made.

  19. Harriet Hall says:

    nwtk2007: This is a science-based blog. We are quite willing to follow the evidence wherever it leads, and we’re capable of changing our minds when the evidence warrants. Instead of evidence, you offer us “medical mistakes kill patients,” “the doctors my patients went to first didn’t cure them,” and “my patients say they like what I do for them.”

  20. nwtk2007 says:

    I didn’t realize that one must present “evidence” for every single statement offered Harriet.

    Much as the one case of CMT induced stroke supported by before and after MRI imaging doesn’t establish causation or provide great evidence for the “correlation” implied, nor does my statement about patients coming to me after a medical doctor has failed to improve their condition.

    I simply offer it based upon 14 years of experience having treated well over 10 to 15 thousand patients. Literally.

    I don’t really care if you find it valid or believable, it simply is.

    Deny it, don’t. Insult me or not, thats the way it is in so many cases. My current case load consists of more than one case such as this where a patient has transfered their care to me in an effort to find relief not found with their medical practitioner.

    Its tuff beans to swallow if your an avid anti-chiro elitest, so don’t try. Ignor it. It’ll just go away, right?

    1. Harriet Hall says:

      nwtk2007 says “I didn’t realize that one must present “evidence” for every single statement offered Harriet.”

      You don’t have to present evidence for every single statement, but you haven’t offered scientific evidence for ANY of your statements.

      For instance: I have pointed out a Cochrane systematic review showing that CMT is no more effective than gentle mobilization for neck pain, and that neither works without adding exercise. Countering a systematic review with a statement that it works for your patients? That gets no brownie points with anyone here, and it just makes you look like a self-deluded true believer with no understanding of science.

  21. Joe says:

    @nwtk2007 wrote “I didn’t realize that one must present “evidence” for every single statement offered Harriet.”

    Can you say “straw man”? I knew you could. Of course you don’t have to justify every statement; but you must have more than anecdote for the substantive claims. In common with your fellow chiros, you do not.

  22. weing says:

    “I simply offer it based upon 14 years of experience having treated well over 10 to 15 thousand patients.”

    Wow! Impressive. How many people did Bernie Madoff fool?

  23. nwtk2007 says:

    Actually weing, I was discussing this with our chief of staff just yesterday; how unbelievable it is and yet true, the sheer number of patients I have had over the years from 1996. There might be no one on the planet who has had more chiropractic patients than I. Your response is all to understandable, and yet, I have not lied one iota. Believe it or don’t. (I say that with a very big smile on my face.)

    And alas, not one subluxation based diagnosis or treatment among them.

    Great experience is a great asset, it truly is. Is is not to be dismissed either. I don’t care to impress you. Not at all. Considering your posts and apparent attitudes, I doubt if I would even like you one bit. But I do enjoy bantering about with you as an exercise in discussion and thought.

    As to fooling the “folks”, well, I doubt if they would tell you they had been fooled. The MD’s, DO’s and PT’s I have worked with over the years would not tell you they have been fooled either. Nope. They certainly wouldn’t.

  24. Harriet Hall says:

    nwtk2007 said “Great experience is a great asset, it truly is. Is is not to be dismissed either.”

    Great experience should not be dismissed, but it must be tested. CMT was subjected to scientific testing and it failed. Sometimes reality contradicts our great experience, and we have to accept the scientific evidence. It must have been very hard for all those bloodletters to give up a treatment that had worked so well in all their centuries of great experience.

  25. WilliamLawrenceUtridge says:

    And how many patients came once, were not helped, and left? How many would have gotten better without treatment? How many are helped by simply having someone talk to them about their condition? The plural of anecdotes is not data. Waving about “in my experience” doesn’t help much since the whole purpose of science is to mitigate the many, many blinders that the human mind has in formulating a true understanding of the world. Without an evidence-based approach to data tracking that is normally not possible for a single practitioner, you don’t know. Hence, experiments over anecdotes.

    Claiming “conventional medicine is flawed” is a standard false dilemma. Conventional medicine knows it is imperfect and invests huge amounts of resources into finding the best solutions to those flaws, then promulgating them to its members. Witness new methods for hand washing, surgical antisepsis, new tools and checklists to ensure no surgical implements are left in the body, extensive, evidence-based discussion regarding the use of antibiotics, vaccination and breast cancer diagnosis. Flaws in one system does not automatically validate another, though many CAM promoters present things as if it were “conventional medicine VS acupuncture/homeopathy/chiropractic/whatever”. It’s never the case, and conventional medicine is constantly changing. Hence the line “half of what you learn in med school will be wrong”. Doctors know they get it wrong, and try to do better. Does chiropractic?

  26. pmoran says:

    Ntwk2007 You say we do nothing beneficial for them yet they express their relief, we document their progress in a quantified manner and return them to their regular daily lives. Not all chiropractors operate at this level of proficiency and effectiveness but many do

    I am sure your attentions are helpful to many, but you will certainly be fooling yourself as to the level of effectiveness of specific treatments for specific conditions.

    We can say this with confidence, because everyone does, whether MD, chiropractor, or quack. Few matters have been more consistently demonstrated within medical science.

    It stems partly from the tendency of most common complaints to spontaneously improve, partly from successes being more obvious than the failures, who just go elsewhere, and partly from the “answers of politeness” of patients who enjoy your attention to their complex human needs.

    And of course your failures, and the people you harm, wind up with MDs, without you necessarily being aware of them, so that we each see the worst of the other.

    Think, man! If you are not aware of the truth of this you are an innocent abroad in a field you only dimly understand.

  27. nwtk2007 says:

    Your comments are interesting if not inflated.

    I treat injuries. My patients are released upon completion of their care based upon their progress, documented on re-evaluation after re-evaluation.

    We do FCE’s and peerformance evals. There are very few patients who we do not follow up on or hear from, especially their referrals to friends and family. Those treated at CARF certified facilities are followed up with on a regular basis.

    I know you would like to emphasize the failures of the treatments we give to our patients, but there are just too few.

    As to your implied comment that they get better based upon the attention they receive, I can assure you, I listen as any doctor should and drive them to improve. It is not feel good treatment. A great deal of their treatment is therapeutic exercise. If they don’t work at it and participate, they will not be a patient for long. And even those are followed up on.

    Its a system of health care that had, at one time, been recommended as the standard for injured workers by some legilators in Texas. Unfortunately, insurance companies have a great voice and much of what can be accomplished is negated by their efforts to avoid paying for that which they are responsible for.

    Regular medicine could take a lesson from us if only they could get over their biases. The medical profession is a paun to the insurance carriers. Its just a matter of time till they start cutting medicine short. In fact, its already begun.

    You think I am unaware of the truth. Far from it my friend. But we deal in realities, that of getting people back to productive lives. Its the ghetto work that we do. You should try it.

  28. Harriet Hall says:

    nwtk2007,

    We explain why science requires us to reject your anecdotes and you only produce more of them. Evidence, please.

  29. weing says:

    “I know you would like to emphasize the failures of the treatments we give to our patients, but there are just too few.”

    You have measured them? Show us the data.

  30. nwtk2007 says:

    Harriet, science doesn’t require that you reject anecdotes as you have so often pointed out in your anecdotal evidence of CMT causing VAD. If it does, then, indeed, we can reject all cases of CMT allegedly causing stroke/VAD.

    Your smoking gun suggests that my experience carries weight, if it does, indeed, for your cases of CMT causing VAD/stroke.

    Weing, you tend to make me tired. You would reject the experience I have had? I sometimes pity the medical practicioner.

    What is the weight of your few smoking guns against my thousands.

    Documented? Yes. Difficult to tally and publish? You know it. Wish I had the time and resources.

  31. weing says:

    “What is the weight of your few smoking guns against my thousands.”

    Huh? It’s your word against mine then? Why do you think its a few smoking guns and not thousands? Why should I believe you that you have thousands? Because you say so?

    Sorry. Real medicine is somehow able to tally and publish. You want an exemption. Who knows? Quantitative analysis of your procedures may show some of them to be effective, others ineffective, and still others dangerous. Don’t you want to know which are which?

    Anecdotes are fine, but only for giving you something to start testing.

  32. pmoran says:

    Ntwk2007:I treat injuries. My patients are released upon completion of their care based upon their progress, documented on re-evaluation after re-evaluation.

    We do FCE’s and peerformance evals. There are very few patients who we do not follow up on or hear from, especially their referrals to friends and family.

    I know you would like to emphasize the failures of the treatments we give to our patients, but there are just too few.

    Still not impressed. Which of the injuries likely to turn up in a chiropractic office don’t have a pronounced tendency to get better by themselves?

    That being so, your uncontrolled clinical observations are worth little more as evidence than a series of patient testimonials stating that they got better after their injury. I am not saying you don’t help any of them, I merely wish you understood how little you really know about your results.

    You and your patients may believe that the treatment helped, but the question remains, as Harriet and others are implying, as compared to what? You can have no knowledge of that.

    With regard to your supposed success with medical failures, some patients take longer to get better. It is wise to remember the old medical saying: ” Blessed is he who treats the patient LAST!”.

    (IIRC, Wally Sampson referred to this as the “Father Sierra effect” — the last saint prayed to!)

  33. nwtk2007 says:

    Yes, I’ve thought of that. But it doesn’t negate what we have done now, does it?

  34. Harriet Hall says:

    nwtk2007 said,
    “it doesn’t negate what we have done”

    No one is denying that you have done something and that your patients have improved. We are questioning whether you understand what you have done and are interpreting it correctly. Whether you and your patients are misattributing the cause of the improvement. This occurs all the time in medicine and is the reason we have come to depend on the scientific method. You seem to be resisting this concept.

  35. BillyJoe says:

    It seems our chiropractor is unaware of, or does not understand, the “post hoc ergo propter hoc” fallacy

  36. Joe says:

    nwtk2007 on 20 Nov 2010 at 9:24 pm wrote “Harriet, science doesn’t require that you reject anecdotes as you have so often pointed out in your anecdotal evidence of CMT causing VAD.”

    As a chiro, you are, by definition, not a scientist; you are ignorant of the topic. And it shows in your arguments and anecdotes, and your willingness to study subluxations for 4 years.

    The topic of this thread is DCs who wish to masquerade as primary care providers. Do you imagine, given your massive experience, that you could assume such a function?

  37. nobs says:

    # nobson 20 Nov 2010 at 2:04 pm
    Your comment is awaiting moderation.
    “# Joe on 20 Nov 2010 at 5:39 am
    Here is another thread, much of it by Blue Wode, that reviews evidence for chiro in low back pain: http://forums.randi.org/showthread.php?t=99523”

    WOW!?? Really? REALLY??

    This “study” has NOTHING to do with “chiropractic”! and (giving you the benefit of the doubt, Joe,) why would anyone claiming to be “science-based” be so hood-winked into believing so?

    Directly from the study cited by Blue Wode/Joe:

    “The randomisation
    envelope also contained a second envelope with the
    participant’s allocation to active or placebo spinal
    manipulative therapy. This envelope was given to the
    treating physiotherapist to open in private…….Spinal manipulative therapy was done by
    15 physiotherapists, in 13 private clinics in Sydney, who
    had a minimum qualification of a graduate diploma in
    manipulative therapy,…”

    What is your agenda? Why would you deliberately misrepresent yourself and the study you cite? I cannot think of any honest reason.

    Clearly, DCs were NOT a part of this study. PTs were the manipulation providers…> NOT DCs. Why would you intentionally repeat such dishonest nonsense? Are you so gullible? or just dishonestly manipulative?

    SOOO YES! – the claims cited below ARE very much indeed “misleading. inaccurate, and distortion”…..and I will add- dishonest.

    Per Joes’s cite:

    “According to the GCC the offending newspapers are:

    Chiropractors ‘are a waste of money’, Daily Telegraph, Rebecca Smith
    Chiropractors ‘are a waste of time’, Daily Mail, Jenny Hope
    ‘Chiropractors may be no use in treating back pain, study says’, The Guardian, Alok Jha”

    Yes they ARE indeed “offending” and This is just ANOTHER example of the egregious misuse of “chiropractic” for dishonest purposes. See:

    Inappropriate/Misuse of “chiropractic”
    http://www.ncbi.nlm.nih.gov/pubmed/7636409?dopt=Abstract&holding=f1000,f1000m,isrctn

    AND:

    http://www.ncbi.nlm.nih.gov/pubmed/16925822

    A professing “science-based”, “critical thinker” would/should have spotted this full on. It is truely disappointing to witness the selective, convienient “science sometimes”(http://smperle.blogspot.com/2010/04/science-sometimes-stroke-and.html) displayed here.

    Let me enlighten you as to a few recent studies that actually incorporated DCs:

    Spine J. 2010 Oct 2.

    ‘The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain.’
    http://www.ncbi.nlm.nih.gov/pubmed/20889389

    AND:

    ‘Study: Starting with Chiropractic Saves 40% on Low Back Pain Care’
    http://insurancenewsnet.com/article.aspx?id=236234

    This IS the evidence. …. Spinal manipulation is indeed effective when it is incorporating the skills of DCs. I can’t speak for PTs. However your ahem..”evidence” has nothing to do with DCs.

    Shame on you for dishonest misrepresentation of the “evidence”!!

  38. nwtk2007 says:

    Right billyjoe, right.

    Joe, you tell so much about yourself with such goofy comments. And I’ve already answered your last question.

  39. Joe says:

    @nwtk2007 Indeed you did answer my question- earlier you acknowledged that chiropractors are not competent to act as PCPs. Where do your fellow chiros get the idea they are, or could be with just a little more training?

  40. BillyJoe says:

    nwtk2007,

    “Right billyjoe, right.”

    Right then, maybe you could use this link:
    http://en.wikipedia.org/wiki/Post_hoc_ergo_propter_hoc
    ;)

  41. nwtk2007 says:

    billyjoe, my experience covers thousands of treatments, literally.

    You must be referring to the case of CMT and a stroke occuring shortly there after. And you would be correct.

  42. nybgrus says:

    @nwtk2007:

    So let me get this straight – you are claiming that in 14 years you have had 10-15 thousand patients? First off, that is a big gap in estimation, but ok, I can understand that. But lets do the math, shall we?

    At 10,000 that means you must have seen 2 new patients every day, 365 days a year, for 14 years straight. At 15 that becomes 3. But lets split the difference and assume that you actually took weekend off and a vacation – that means you had between 3 and 4 brand new patients come in to your office every single day it was open for the last 14 years running. Does that seem like a stretch to anyone else? Especially considering you need to schedule in follow-up patients and your regulars, which, after just a few years would number a few thousand, meaning you are seeing, what? 20+ patients a day with 3 or 4 being completely new to your practice every day?

    Or perhaps you are just referring to individual patient visits, regardless of whether it is a new or follow up patient. Then we are talking about a practice that sees only 4 patients per day (tops) and that seems pretty limited and a rather boring day.

    Maybe I am missing some of the consultations at the hospital that you do? Oh wait….

  43. nwtk2007 says:

    Interesting math. In actuality, from 1997 till about 2005 my clinic would get well over 250 to 300 new patients a month, I’d say averaging 10 to 15 new patients per day. Even at our reduced capacity, my clinic gets about 10 to 15 new patients per week, mostly walk ins and internal referrals.

    In terms of number of visits, that would range from 180 to 250 per day much of the time.

    As the director of the clinic, all patients were my patients and although I had many associate doctors in the clinic, I saw all new patients and managed the care of every single one. In terms of patient visits, I, myself, would see 40 to 50 on average per day, the associate doctors would see the rest and I had a fully equiped therapy bay as well as therapeutic ex/active rehab area.

    You can now do more realistic math if you wish.

  44. Harriet Hall says:

    nwtk2000,

    Forget the math. No matter how many patients you’ve seen, the plural of anecdote is not data. Either give us some real evidence or admit that you don’t have any. Or just go away.

    The whole point of science-based medicine is that the old “in my experience…” claim is unreliable.

  45. nwtk2007 says:

    In your experience how many cases of stroke have you seen caused by CMT?

    I can at least claim thousands upon thousands of cases were patients have benefited greatly from both cervical and lumbar CMT.

    I think my evidence for the benefits of CMT, both cervical and lumbar are far and away superior to your “evidence” that CMT causes VAD/stroke.

    Why not admit that you don’t have any evidence that CMT causes VAD/stroke.

    Or, why not give up the constant criticism of chiropractic’s benefits and get off the anti-chiro band wagon. If anything, its hypocritical.

    I guess we could publish case after case study, over and over again, hundreds at a time and maybe that would compare favorably to your few case studies of alleged VAD/stroke caused by CMT.

    1. Harriet Hall says:

      nwtk2007 said, “I can at least claim thousands upon thousands of cases were patients have benefited greatly from both cervical and lumbar CMT.”
      Well good for you! That puts you in the same league as all those doctors over the centuries who claimed thousands of cases where patients benefitted from bloodletting, and all those homeopaths who have claimed thousands of cases where patients benefited from their dilute remedies.
      I found a Cochrane review showing that CMT is no more effective than gentle mobilization and that neither is effective without adding exercise.
      The plural of anecdote is not data. Either produce evidence that CMT is effective or admit you don’t have any.

  46. David Gorski says:

    Well good for you! That puts you in the same league as all those doctors over the centuries who claimed thousands of cases where patients benefitted from bloodletting, and all those homeopaths who have claimed thousands of cases where patients benefited from their dilute remedies.

    Or all those thousands upon thousands of people that faith healers claim to have cured. :-)

  47. Jann Bellamy says:

    @ nwtk2007: “Why not admit that you don’t have any evidence that CMT causes VAD/stroke.”

    There IS evidence that CMT causes VAD/stroke:

    Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM. Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke? The Neurologist 2008; 14: 66-73.

  48. WilliamLawrenceUtridge says:

    @nwtk2007

    You’re still missing the point – regular record keeping has virtually nothing to do with scientific research. At best the records could be used as a primary source of data that could be mind to produce a finding. A doctor of any sort does not do research when they keep charts; at best, if they did an analysis of those charts to produce some sort of scientific paper, that could be considered a very basic research study. Even then, there would almost certainly be a large number of flaws and biases.

    Actual research in clinical settings is maddeningly specific, extremely complicated, and requires extensive testing and an ongoing, constant effort to determine, and guard against blind spots and possible flaws. Actual science also rarely comes to a conclusion after a single study, it arrives at a tentative conclusion after a program of study that often takes millions of dollars and years if not decades of research that is plagued with false starts, blind alleys, flawed assumptions and surprising, often disappointing. results.

    Frankly, it’s a wonder anything gets discovered or confirmed at all :)

    An actual scientific study actively attempts to test, ideally disprove, the hypothesis in question, through an extremely pessimistic review of the evidence – where can I have gone wrong? Is my control group truly representative in all ways to my experimental group? Are there any biases? Have I forgotten anyone? How good is my blinding?

    You can’t do that through vague memory. As a human being, you are naturally built to forget errors, completely skip over holes in your data, seek confirming information, ignore and discount disconfirming information, and so forth. Research on humans is expensive, time consuming and difficult. There’s a reason there are now PhDs in research methodologies and statistics.

    The reason many of the commentators here are harping on your use of anecdote being flawed is because they appreciate the difference between record keeping and a scientific paper that has undergone peer review. Record keeping is little more than systematically collected anecdotes. A slight improvement over simple anecdote, but still just a starting point.

    I went to a chiropractor for years. Both of us considered his treatments successful. I’ve stopped going, and lo and behold, most of the symptoms I used to visit the chiropractor for now disappear on their own after a couple days. There’s my anecdote, so who wins? On the other hand, my wife used to have severe migraines. Visiting the chiropractor helped but she no longer goes, and most of her problems have the same cycle of appearing and vanishing over a couple days. Which anecdote is correct – yours, mine or my wife’s? We can’t tell, it would take a study.

  49. nobs says:

    # Jann Bellamyon 22 Nov 2010 at 2:42 pm
    @ nwtk2007: “Why not admit that you don’t have any evidence that CMT causes VAD/stroke.”

    There IS evidence that CMT causes VAD/stroke:

    Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM. Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke? The Neurologist 2008; 14: 66-73.

    NO Jann- Your cite is NOT “evidence that CMT causes VAD/stroke”, and is discussed in the following cite:

    ‘Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession?’

    “……Following these studies was a paper that attempted to answer the question, “Does cervical manipulative therapy cause vertebral artery dissection and stroke?” [43] by reviewing the literature up to that point and “[using] Sir Bradford Hill’s criteria for causation as well as the strength of the research designs to present and evaluate the evidence for or against a causal relationship”. This study concluded that the criteria of temporality (purported cause preceded effect), dose-response (higher rates of exposure associated with higher rates of disease), consistency of association and biological plausibility supported a cause-effect relationship between CMT and VADS. The criteria of strength of association (the size of the relative risk), specificity (one cause leading to one effect) and analogy (an analogous cause-effect relationship already established for a similar exposure and disease) were deemed equivocal or not in support of a cause-effect relationship between CMT and VADS. It was deemed that the criterion of reversibility (reduction in exposure leading to a reduction in rate of disease) could not be adequately satisfied in answering the posed question. They concluded that their analysis “support(s) weak to moderate strength of evidence for causation between CMT and VAD and associated ischemic stroke, especially in young adults” and called for research “which would employ superior study designs” [43]. They did not discuss the potential confounding factor discussed in the Rothwell, et al [37] and Smith, et al [38] papers of neck and head pain patients presenting to chiropractors with a dissection already in progress……”

    http://www.ncbi.nlm.nih.gov/pubmed/20682039?dopt=AbstractPlus&holding=f1000,f1000m,isrctn

  50. Harriet Hall says:

    The discussion of stroke is a diversionary tactic. Let’s not get sidetracked. The available evidence, while not of optimum quality, is sufficient to have convinced the majority of us that stroke is a risk of CMT. This was thoroughly covered in previous threads and we need not revisit it here.

    But even if CMT were perfectly safe, it would not be justified without evidence of benefit. A Cochrane review indicated there isn’t any benefit. Instead of evidence to counter that systematic review, all we are getting is “in my experience” and “patients like it.” Because they have no credible evidence.

    How about admitting that? Is it so hard to say “I don’t have any scientific evidence that it works, but I believe it does, and my patients seem to like it, and I want to keep doing it because it offers me a good livelihood with grateful patients.”

  51. nwtk2007 says:

    I think all doctors in all areas of health care operate with the same premise, that they rely on their experience to know what works and that the patients “like” the treatment, that it makes them feel better. I would point out that there is not much in the way of “feel good” in post-op rehab. And CMT is not exactly the most pleasant thing when applied to a patient with a sprained neck/back but the benefit of the increased ROM is undeniable.

    I would also point out that medical doctors dispense pain medications such as hydrocodone and muscle relaxers pretty darn indiscriminantly, which are nothing but feel good treatments with no therapeutic benefit at all (much more closely related to your blood letting example). In extreme cases these and other medications are used for years and years, resulting in utter dependence upon them.

    At least with CMT, although in your opinion not backed up with sufficient research to justify its use such that we know the patient actually benefits, there is no risk of drug induced dependence or any prolongation of care, which is apparently, according to the AMA, another side effect of these narcotic drugs. And as you said, when combined with exercise, the CMT has, even in your statements, been shown to have benefit.

    Also, since in many cases due to what ever reason, we have to defer from doing CMT, we see the patients progress to be much slower, even if therapeutic exercise is employed.

    But as I said, don’t discount experience. Any doctor in practice for a number of years; any surgeon, internist, even dentists will tell you, it is invaluable.

  52. Harriet Hall says:

    Yes, doctors rely on their experience, but the whole thrust of EBM and SBM is to persuade them not to go by experience alone but to ask for evidence – and to disregard experience when the evidence contradicts it. As I mentioned in my recent post on chronic pain, narcotics do have therapeutic benefit: relieving pain adequately with narcotics in acute injuries can reduce the risk of chronic pain. Anyway, it is a false dichotomy to compare CMT to narcotic drugs: those are not the only two treatment options. And I have tried to explain to you before that criticizing MDs does nothing to validate chiropractic: you are using the tu quoque logical fallacy again. Experience is indeed invaluable, but if you don’t understand its limitations and the need to verify with science, experience can be devastatingly misleading.

    Mark Crislip has said that the three most dangerous words in medicine are “in my experience.”

    Your continued comments demonstrate that you just don’t seem to “get” science-based medicine.

  53. weing says:

    Check out
    http://www.nejm.org/doi/full/10.1056/NEJMoa013259
    This is an article that showed arthroscopic knee surgery for osteoarthritis of the knee was no better than placebo. Do you think that I can recommend this for my patients with OA of the knee? What should I do if a patient tells me that his orthopod is recommending this for his OA of the knee? If you have studies that show chiropractic is beneficial for certain conditions, then I can recommend it to my patients with those conditions.

  54. nwtk2007 says:

    Not agreeing with the totality of SBM is not to imply a lack of understanding it. I would imagine that many, if not most, doctors will not simply disregard experience in light of a small number of studies.

    Take, for example, weings example of arthroscopic surgery. On an average it seems to indicate that the surgery is ineffective for a specific condition, osteoarthritis. I doubt if it will be extrapolated to include meniscal tears and ligamentous ruptures.

    We cannot conclude that CMT has no benefit across the board for all conditions based upon any study to date. In fact, in the chiropractic journals there are age old studies where aspects of cervical and lumbar biomechanics are substancially altered for the better when CMT is employed. Functionality is a now known key to rehabilitation of damaged and injured joints in all areas of orthopedics. I use many methods in the restoration of functionality, but CMT, in my experience, is the most therapeutic.

    It even costs less, so there is no “this makes me a good living” type of thing going on. Therapeutic exercise alone is three to five times the cost of CMT (or more), especially if done in a thorough and supervised manner.

  55. Harriet Hall says:

    “Not agreeing with the totality of SBM” (?!)
    “in my experience” again!!
    I would laugh, but it’s really more sad than funny.

    It is not up to us to prove that CMT doesn’t work for any possible condition. It is up to you to give us evidence that it works for any specific condition. If you could do that, we could then go on to discuss the relative safety and effectiveness and cost of all available treatments for that specific condition. But you can’t; all you can do is state your beliefs based on your [unreliable] “experience.”

  56. nwtk2007 says:

    Harriet, you are so intent on winning an argument that you don’t even see the point I make or care to try to understand it. You see science as the ultimate guide as it might be, for you, some sort of religion. If anything is sad, it is that.

    I suspect that in a world where our paths cross that I would in no way refer a patient to you for anything. To me, you seem to have lost the art of health care. Your proclamations of superiority are infused into almost all of your responses; as would your interactions with real people who need help from their health care provider.

    I’ve fully admitted the weakness of the CMT research, but have pointed out that great experience should not be discounted in your analysis of what treatment might be best for your patients. As to the subject of this thread, I have even pointed out that chiropractors are not equipped to be PCP’s, but I would say that with your air of superiority and dogmatic belief in science for science sake, that you are not either.

    You say you would laugh but its really more sad. I think I see some tarnish on your armor. And the sad thing, actually, is that you feel the need to wear it. How biblical you are.

  57. rwk says:

    @nwtk2007

    Bravo!

  58. weing says:

    “I’ve fully admitted the weakness of the CMT research, but have pointed out that great experience should not be discounted in your analysis of what treatment might be best for your patients.”

    Oh really! Why? Would the surgeon recommending arthroscopy for OA of the knee because of his vast experience make me want to trust him? I wouldn’t. I would say he is either trying to line his pockets or is deluded. No way would I ever refer to him again.

  59. Harriet Hall says:

    nwtk2007,

    I treasure the insults I get when my interlocutors have run out of effective arguments. I’ve never been called “biblical” before. Thank you for adding to my collection.

    It is out of humility that I criticize beliefs based on “experience” because I am well aware that my own experience has frequently misled me. Those who think their own experience can’t mislead them are sadly deluded. We are all human.

    I think you are getting at one truth: when we don’t have adequate evidence we still have to do something. We are reduced to making an informed guess and offering our patients untested treatments. The self-aware practitioner will tell his patient he is trying something that has not been scientifically proven to work but that his experience with other patients suggests might help. The self-deluded practitioner will tell his patient it is an effective treatment and he knows it works because of his great experience. I leave the reader to decide which approach is that of one who thinks himself superior.

  60. Jann Bellamy says:

    @nobs

    Miley et al. most certainly did discuss confounding:

    “Furthermore, the association between CMT and VAD may also result from confounding. The situation of confounding could occur if, for example, a patient has neck pain due to arterial dissection of etiology other than CMT and the patient subsequently seeks CMT for the symptom of neck pain. In this case, it would be unclear to a clinician if dissection and stroke actually preceded or followed CMT.”

    That did not prevent the authors from concluding: “Weak to moderately strong evidence exists to support
    causation between CMT and VAD and associated stroke.”

    I am assuming by their use of the word “evidence” they meant “evidence,” so I am not sure how you draw your conclusion that there is not any “evidence.”

    Miley et al. also discuss Rothwell and Smith:

    “Rothwell et al conducted a population-based nested
    case-control study to test the association between CMT and
    VAD. Adding to the compelling evidence of temporality, the
    results for those aged 45 years revealed VAD cases to be 5
    times more likely than controls to have visited a chiropractor
    within 1 week of the VAD.”

    “The results [of the Smith study] revealed that VAD was independently associated with CMT within 30 days (OR 6.62; 95% CI, 1.4 –30.0).”

    The editorial from Chiropractic & Osteopathy you cite ultimately relies on the Cassidy study in Spine as somehow negating all other evidence, a conclusion refuted on SBM by Dr. Crislip.

    In any event, having compounded the problem myself, I do hope we can all get away from this discussion and back to the point of my post: “The DC as PCP.” I would love to hear from the chiropractors what they think of this move by the CCE and others.

  61. WilliamLawrenceUtridge says:

    nwtk2007 – you really are missing Harriet’s point. And mine for that matter. Doctor’s should rely on experience only in the absence of better evidence, and should allow that better evidence – better collected, better analyzed, better representing the real world – to override their experience. Scientific inquiry that undergoes scrutiny through peer review, replication and extension is always better evidence for pretty much anything than just experience.

    Always.

  62. nwtk2007 says:

    Amazingly enough, I am not in disagreement with you on that.

    My point would be that if, by experience, a patient is having a positive outcome with a certain type of treatment, why would I stop it. Because the very few studies (and I mean few) are telling me that it has little if any benefit?

    By the same token, if a patient is not having a favorable outcome when being treated by “scientifically proven” treatment method, do I discount the patient response, ignore my experience which is telling me the outcome is not going to be favorable, and thus continue to the exclusion of all else? I don’t think so.

    I see this repeatedly when various powers that be refer to guidelines (apparently based upon science and evidence) which say a patient with a certain type of injury should be well by now, or even more loony, that they should still need treatment because the scientific guidelines say so, even though they are obviously fine and back to pre-accident status.

    If all we need is to know what is “scientifically proven” and what is not, then any 1st year doctor should be as good or better than the “experienced” doctor in determining a patients treatment plan. It just ain’t so.

    What it is that I don’t understand is how you and Dr Hall don’t understand that favorable outcomes, seen thousands of times, measured and quantified as opposed to other outcomes with different treatment methods, believe you should ignore this and stop or change the treatment, even when the treatment being given is getting good results as opposed, as I said, to other, more “accepted” or “scientifically supported” treatment methods which are simply not as effective. If I did that, I would have patients beign released from care prior to an attainment of MMI, while still in pain and not able to function adequately. Then, it would be me that they would be telling their new doctor had failed them.

    The comments would be that I had done nothing for them and that they are still hurting and unable to function as they did prior to their injury.

    Believe me, I understand your point very clearly, I just won’t take it to the nth degree that you would imply that you do.

  63. Harriet Hall says:

    Did I ever suggest you should stop a treatment that seems to be getting good results? I don’t think so. I’m just trying to get you to understand that without scientific testing you can’t be sure the treatment is truly responsible for the results. You could be right or you could be wrong. You are over-confident about the value of your “great experience.”

    Keep doing what you’re doing, just admit that your treatments are based on your beliefs rather than on hard scientific evidence, and admit that there is at least a small possibility that future testing might find your treatments to be useless or harmful. I sincerely hope that none of your CMT patients will ever have a stroke for any reason.

  64. Joe says:

    @nwtk2007 on 23 Nov 2010 at 12:41 pm “If all we need is to know what is “scientifically proven” and what is not, then any 1st year doctor should be as good or better than the “experienced” doctor in determining a patients treatment plan.

    Obviously that is recognized, it is why, in distinction from DCs, one needs some years of postdoctoral study to be licensed in medicine.

    On the other hand, http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53681&MERCURYSID=9ac341fe894c032f3c98ee00405aa420Sometimes a [customer] asks me, “Who did you practice on when you were learning to adjust?” … But alas, we practiced on each other ” … “As a greenhorn DC, I clearly recollect … Since I was just out of school and without any meaningful experience, … ”

    A further distinction is that chiros do not learn what is “scientifically” proven.

    That is why chiros are not prepared to be PCPs, and why a small amount of additional training will not make them so. Will someone tell us why they think a small amount of additional training can compensate for their obvious quackery.

  65. pmoran says:

    “ –favorable outcomes, seen thousands of times , measured and quantified as opposed to other outcomes with different treatment methods –“
    —————————————————-

    – but still merely your perceptions, Ntwk2007. We are trying to alert you to a very discomforting lesson that the mainstream has had crammed down its equally reluctant throat on numerous occasions.

    Remember that the studies are designed to strip away spurious perceptions as to intrinsic treatment effectiveness.

    In effect they provide a lot of little anecdotes to add to yours — but these ones can be examined in such a way as to “control for” false perceptions: the patients who would have gotten better just as quickly anyway, the “answers of politeness”, the confirmation biases, and various non-specific aspects of medical attentions including placebo reactions.

    So if you wish to be taken seriously, you must come up with a plausible explanation for the discrepancy between “my experience” and “what the studies show”.

    Since this science stuff seems a bit new to you :-) , I’ll try to help, but I am not sure that any plausible additional hypothesis yields satisfactory outcomes for chiropractic.

    “ I am more skilful” (than the practitioners used in the studies) demands better evidence than your opinion, and it is belied by the fact that chiropractors use dozens of different techniques while all claiming brilliant results.

    Better might be: “my most spectacular results (i.e. the ones entrenching my opinions) occur only now and then, not frequently enough to influence statistical outcomes in clinical studies of practical size”.

    That is tenable scientifically. It might even be true, for all I know. But it is damaging for the cost-effectiveness of chiropractic care, as well as firmly eliminating potentially harmful CMT as a first treatment option for any condition.

    Do you have anything better?

    In any case, chiropractic should have been doing more of its own scientific homework, finding out precisely how and when chiropractic methodology IS a uniquely useful medical tool, rather than using it as a money-spinner that even after a century of use is still only minimally distinguishable from any other pre-scientific medical modality.

    Nevertheless, I recognise that whether chiropractic has a secure place within any medical system will be determined by a wider range of considerations, including the fact that patients like it, and there is nothing obviously better to do with the common bad back.

  66. rwk says:

    @joe
    Do you have any medical training whatsoever or are you a
    self-taught anti- alternative medicine hater?

    Joe says
    “Obviously that is recognized, it is why, in distinction from DCs, one needs some years of postdoctoral study to be licensed in medicine.

    Only 20 years ago, you could could get a license after your one year internship as a D.O. I’m not sure about an MD degree but it couldn’t be that different.
    Things are different now, but there are still plenty of medical practitioners from those days.

    Joe says
    That is why chiros are not prepared to be PCPs, and why a small amount of additional training will not make them so. Will someone tell us why they think a small amount of additional training can compensate for their obvious quackery.

    What about nursing practitioners? They get a masters degree same
    as the degree offered by NUHS. They function as PCPs. Right?
    Have you looked at the curriculum for the NUHS degree? It’s a
    three year residency.

    Of all the people that spout off about chiropractors on this site
    you come off least qualified to do so. I suspect you have no formal
    training in any of this.
    .

  67. nwtk2007 says:

    pmoran, what is it you mean by spruious perceptions?

    When patients are evaluated, there is little if any difference in how you or any other competent health care provider would assess a patient. I think we are a bit more sophisticated than you might think although, there is no blinded aspect of regular progress evals as patients go through their treatments.

    You mention the “answers of politeness”, the confirmation biases, and various non-specific aspects of medical attentions including placebo reactions.” as a possible source of false perceptions. Maybe. I guess how politely we ask a patient to bend forward or backward or side to side as in ROM studies could effect their ability to do so, or how we ask them to rate their pain one to ten, or how we ask them anything or just our attentivenes could. Not sure how. Or I guess when we observe swelling in joints, palpate muscle spasms, perform orthopedic tests, neurological test such as reflexes, pin wheel evaluations, two point discrimination tests, etc, etc, all part of regular assessments, the we we speak or talk or what ever could effect that. I’m just not sure how.

    There is, also, that participatory aspect of physical medicine which will inevitably vary from one dr/pat relationship to another. Just as some football coaches can’t win with a given amount of talent and others, with the very same talent to work with, can finish a season undefeated (Cowboy fan hopeful), there are going to be those in the field who can get patients to put more into their recovery than others and benefit more from a given treatment from one doc and less from another. Just this aspect of physical medicine might make it nearly impossible to truly assess the effectivenes of one physical modality over another. But as you said, the chiro’s should have been working at it a bit more.

    And yes, a patient might want us to feel like we are helping them, but that isn’t going to effect many aspects of their examination findings. Who knows.

    And yes, I guess I would have to admit that I could have treated such a huge population base and essentially every one of them would have gotten fully well on their own, without any input from me or the treatments involved at all. Being a bit sarcastic at this point.

    I also don’t recall having used the words “I am more skillful” in any part of my comments.

    I find it interesting that you would say that there is obviously nothing better to do with a common bad back .. than, I guess chiropractic .. ? Its true, I get a few folks who come by because their doctor has sent them off with the usual “arthritis” diagnosis and nothing more in the way of treatment than pain/inflammation meds and “good luck with that”. True enough although I treat, almost exclusively, injuries which, by their very nature, preclude the “I like that” patient response. Lets face it, its rehab, not massage therapy.

    At any rate, it is a very, very complex issue; that of being able to show to any great degree at all, that any doctor anywhere is doing something for a patient which is absolutely the correct and necessary thing to do, such that the patient would not fully recover with out the intervention, isn’t it?

  68. Joe says:

    It seems we have a live one.

    @rwk on 23 Nov 2010 at 5:25 pm How do you suppose your training in chiropractic subluxations prepares you to be a PCP?

  69. WilliamLawrenceUtridge says:

    Answers of politeness, the confirmation biases, and various non-specific aspects of medical attentions including placebo reactions are not possible sources of false perceptions, they are recognized traps that researchers and in particular practitioners can fall into. Any practitioner that can use a truly objective test – where a machine does the counting – has a huge advantage for any experimental intervention or treatment. Most of the tests you mention have a fair amount of judgment on the part of the practitioner or patient. See the Hawthorne effect as a start, but there’s a ton of potential biases that exist, and any basic research methodology book could list at least some of them. Snake Oil Science by R. Barker Bausell would be a good place to start. The point is without stringent controls and research methodologies, you simply can’t know if your patients would have gotten better or not. Symptoms are cyclical. Patients naturally heal. They visit doctors of all stripes when pain is at the worst – which is exactly when regression to the mean could occur.

    Incidentally, the common bad back is nearly the worst possible health problem to compare “usual care” to complimentary and alternative approaches. Usual care is widely known to be flawed and ineffective, meaning there is no gold standard of evidence-based treatment to compare them to. Claiming chiropractic is comparable to conventional care in terms of treating a bad back is actually rather damning evidence that it’s not doing to much good.

    Yes it is complicated, and that’s what we’re trying to underscore – you can’t just assume your clinical experience is valid, because there is an extremely complicated potential set of alternative explanations for why a patient improves. Without a very strong methodology, you simply don’t know. That’s why you need good research.

  70. pmoran says:

    Ntwk2007: pmoran, what is it you mean by spruious perceptions?
    ————————–

    What I said was ” — spurious perceptions as to intrinsic treatment effectiveness”.

    I am not sure if you are being deliberately obtuse and beside the point in response, or whether I am merely expressing myself poorly. How could you misunderstand ” answers of politeness (from patients)”?

    It might help avoid misunderstandings if we confined ourselves to specifics.

    If it is your claim that specific aspects of chiropractic care, such as HVLA manipulation, are uniquely effective for any condition, let us have that on the table so that we both know what we are talking about. This is what we have assumed you are talking about, not the generic physiotherapeutic modalities such as exercise that you occasionally refer to.

    Also the “coaching” aspect to patient care would come under “non-specific aspects of medical attentions”.

    Some of these concepts do seem to be new to you.

  71. rwk says:

    @joe
    you keep bringing up the subluxation word. None of the other
    chiropractors bring it up on this blog nor defend it. I’ve told you
    before that NUHS downplayed that word and was only taught in an
    historical concept, all 3 hours of that class. So you read Dynamic Chiropractic,a trade magazine roughly equivalent to WebMD
    looking for any questionable comment.
    You’re not qualified to seriously participate.

  72. Harriet Hall says:

    rwk told Joe
    “You’re not qualified to seriously participate.”

    And chiropractors who resort to insults, ad hominems, tu quoque arguments and other logical fallacies, and instead of evidence can only repeatedly offer claims of experience (after being shown why experience does not qualify as credible evidence) are qualified to seriously participate?

    Joe misspoke about the requirements for medical licenses: doctors can be licensed after one year of post-graduate residency training, although at least two more and often many more years of training are required to qualify as a specialist. But Joe clearly understands what science-based medicine is all about, and he has shown himself more qualified to seriously participate in these discussions than certain other people I could mention.

    Nobody elected you judge. You are not qualified to determine who is qualified to participate here. All are welcome; some are more welcome than others.

  73. weing says:

    “believe you should ignore this and stop or change the treatment, even when the treatment being given is getting good results as opposed, as I said, to other, more “accepted” or “scientifically supported” treatment methods which are simply not as effective.”

    But you haven’t proven that claim scientifically. That would be like me prescribing antibiotics for viral infections and saying that I am getting good results and should continue to do so.

  74. Dawn says:

    @rwk: well, let’s get all your errors pointed out.

    D.O.s are not licensed “after one year internship”. First, DOs, like MDs have attended a 3-4 year post-undergraduate program (like medical school, only for DOs). Their training is almost identical to MDs. After they, like MDs, graduate from their program, they take the first part of the board exam. IF they pass, they are doctors. Internship and Residency are not required to be licensed. They are required for most specialties, and most physicians (MD, DO) do them.

    As for nurse-practicioners: They have usually completed 2 year master’s degree in primary health care. They do NOT act as PCPs, nor are they licensed to do so. They ARE licensed to act as Nurse-Practitioners, which may include doing annual exams, dealing with minor illesses, etc. However, in EVERY state, a NP MUST practice under the coverage of a physician. They are not independent practitioners. They are NOT PCPs.

    If a DC wants to, like a NP, work under a licensed physician, after obtaining the additional training a NP has to get to be licensed as a NP, then I am OK with it. But they are NOT qualified to act as PCPs.

  75. Thanks, Dawn, for the clarification. rwk’s representation of NPs was bugging me, since it didn’t line up with my experience with NPs, but I lacked the time for research and a lengthier post.

    Pies, must bake pies.

  76. nwtk2007 says:

    weing – “That would be like me prescribing antibiotics for viral infections and saying that I am getting good results and should continue to do so.”

    This is not a good example of what I was saying. Hopefully you would not prescribe antibiotics for a viral infection unless you felt that a secondary bacterial infection was the real culprit in the patients illness or was resulting in symptomatology that was more deleterious than the viral infection itself.

    No, what I was saying is that you and Dr Hall “seem” to be saying that you would forgo a working, valid treatment and instead, use another treatment due to its superior “scientifically” proven background, even if the more “scientifically” proven treatment was, in the present case, less effective.

    You have to assess the patient and make a judgement as to their progress. Are you saying also that you can’t really believe the results of your assessment; that even though the patient appears to be progressing based upon your assessment and judgement as a doctor, you should switch to the more “scientifically” proven treatment?

  77. rwk says:

    @Dawn
    if you read my post carefully I said I did not say that DOs or
    even MD’s get licensed after a one year internship. They formerly
    did, at least up to the 1990s. I knew lots of them who did. Many are still in practice.

    From everyone’s favorite reference site:
    http://en.wikipedia.org/wiki/Nurse_practitioner
    excerpts:
    NPs can serve as a patient’s primary health care provider
    In the United States, because the profession is state-regulated, care provided by NPs varies widely. Some nurse practitioners work independently of physicians while, in other states, a collaborative agreement with a physician is required for practice.

    @Harriet Hall
    Are Joe’s posts not generally insulting and sarcastic towards
    chiropractors?

  78. Harriet Hall says:

    nwtk2007 said
    “you and Dr Hall “seem” to be saying that you would forgo a working, valid treatment and instead, use another treatment due to its superior “scientifically” proven background, even if the more “scientifically” proven treatment was, in the present case, less effective.”

    No, you’re still missing the point. I am saying that just because a treatment seems to you to be working and valid doesn’t mean that it really is, and you should keep that in mind while you continue to offer that treatment. If your treatment has not been tested, you have a poor basis for choosing it in the first place – you are going on unreliable experience and belief. If you are using a treatment that has not been tested, you can’t say with any certainty that another, tested treatment was less effective. The most you could possibly say is that you tried a tested treatment and the patient said he didn’t feel better and his ROM was unchanged, then you tried an untested treatment and the patient said he did feel better and his ROM improved. You could still be committing a “post hoc ergo propter hoc” error.

    Doctors have made many “post hoc ergo propter hoc” errors over the centuries. We have identified many of these errors and changed our ways thanks to the scientific method. We are well aware of our human psychological foibles and are trying very hard to guard against them. You seem to think your great experience somehow protects you from such errors; it doesn’t.

    Given two treatments, one tested and one not, it would seem prudent to try the tested treatment first. If the patient doesn’t respond to the tested treatment, it is reasonable to try an untested treatment – but only with full disclosure to the patient of the current state of knowledge and any possible risks, not with an unfounded reassurance that the untested treatment is effective and safe.

  79. JMB says:

    Although the standards are not universal, in the United States the majority of licensed MDs and DOs have a (typically) 4 year bachelors degree, 4 years postgraduate education (resulting in MD or DO degree), and 1 year post doctoral education (what used to be called internship is now usually called first year of residency). The college degree, doctoral degree, post doctoral 1 year of education, and passing competency exams are the qualifications for license (in addition to continuing education requirements). The requirements for board qualified varies considerably with the field, on average I would guess between 3 – 4 years of postdoctoral education. To be board certified (these boards are the professional societies of the specialties, which include primary care specialties), one must also pass certain tests, and in some cases documentation of treated cases. Board certification is not determined by state boards of health, something that is potentially confusing.

    So your typical board certified physician has 12 years of education after graduating high school. If you follow the typical pathway, you can be licensed to practice medicine 9 years after graduating high school. There was one MD program that I was aware of that would take high school graduates and grant an MD degree after 6 years of education, but my understanding is that they preferred people with more life experience after high school, often those with other college degrees that lacked the science prerequisites. After the scandal in medical education outlined in the Flexner report of about 1910 (mentioned in a recent SBM blog), the education of a physician was designed to be more similar to that of a doctorate degree in natural sciences. That was in part a response to the presence of quackery in medicine.

  80. Harriet Hall says:

    rwk,

    1. Let’s get back on topic. The question is whether DCs should be PCPs. The licensing laws governing other practitioners don’t really help us answer that question. For that matter, lots of MD specialists are poorly qualified to act as PCPs even though their license authorizes them to do so: pathologists are a prime example.

    2. Yes, Joe is frequently insulting and sarcastic. I have repeatedly asked that commenters comment on the content of posts rather than insulting the writer. I try to do that, but sometimes it’s hard when the provocation is great.

  81. weing says:

    “Given two treatments, one tested and one not, it would seem prudent to try the tested treatment first. If the patient doesn’t respond to the tested treatment, it is reasonable to try an untested treatment – but only with full disclosure to the patient of the current state of knowledge and any possible risks, not with an unfounded reassurance that the untested treatment is effective and safe.”

    I usually reassess my diagnosis in this situation.

  82. WilliamLawrenceUtridge says:

    @nwtk2007

    I must echo Hariett Hall here – you can’t know if a treatment is “working” or not without stringent controls. Clinical experience is a valuable supplement to scientifically proven treatments, particularly when choosing between them. But as a primary means of deciding on a course of treatment (or deciding between more than one) without a scientific basis it’s risky to the patient.

    It’s overall unclear why a doctor who specializes in treating physical symptoms should be granted the ability to prescribe drugs and surgery. Why would a physiotherapist need to prescribe antibiotics? At best, a limited set of medications that apply to musculoskeletal complaints would be indicated. A chiropractor should not try to treat the sniffles, bar the occasional sequelae like a sprained muscle from sneezing and the like.

    “No, what I was saying is that you and Dr Hall ‘seem’ to be saying that you would forgo a working, valid treatment and instead, use another treatment due to its superior ‘scientifically’ proven background, even if the more ‘scientifically’ proven treatment was, in the present case, less effective.”

    The overall point is, without proper research, you can’t know a) if either treatment is effective or b) if one is more effective than the other. You shouldn’t start a treatment without a realistic evaluation that gives you a risk:benefit ratio. Much like the current debate over CCSVI and “liberation” treatments, without knowing the benefits, you have no idea if there is any reason to undertake even a low-risk treatment.

  83. Joe says:

    nobs on 21 Nov 2010 at 10:42 am refers to an article in The Lancet that found no benefit from manipulation for low back pain. Nobs would like us to know that it pertained to PT, not chiro. However, the Lancet study was included in the Bronfort review of chiro done for the UK General Chiropractic Council. http://www.zenosblog.com/2010/11/where-the-evidence-leads/

    That is typical of chiro, when asked for evidence they often point to research by PTs and osteopaths, etc. This is despite claims to unique training and effectiveness of chiro. Yet, when something doesn’t work out for them, they call foul- it wasn’t strictly chiro. They have been caught-out here.

    But wait, you say that’s not enough, you say you want more? Of the 85 conditions/treatments addressed in the Bronfort review, 32% specifically refer to reflexology, PT, craniosacral osteopathy, etc. Many of those that are simply termed “manipulation” refer only to osteopathy, PT, etc. [All the necessary citations are in the link I provided.]

    Finally, one can find a link to the latest survey of chiros, by chiros, here http://www.ncahf.org/digest10/10-47.html to see their dominant delusions and reasons why they should not expand their privileges.

  84. Joe says:

    Jann Bellamy is correct to worry about giving chiros prescribing rights with so little training. There is a further problem with them as PCPs since they cannot diagnose illness.

    See http://www.chirobase.org/02Research/jwk.html in which John W. Kinsinger, M.D., describes visits to nine chiros complaining of symptoms that indicated a potential emergency. None of the chiros eight of the chiros seemed oblivious to the possible meaning of the symptoms while the last recognized the potential illness but did not know it was an emergency.

    We also know that their “clinical education” consists primarily of practicing on each other and a few young, healthy friends they can persuade to come to their schools’ clinics.

  85. Joe says:

    There has been a follow-up to the opinion cited in the OP concerning the CCE and elimination of ‘chiropractic subluxation’ from description of chiro http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=55039 (This links to the cite in the OP.)

    Despite the chiros posting here trying to distance themselves from the concept, the overall business seems to be jealously guarding their ownership of that fairy tale.

    There is also a move afoot in the UK to drop the term ‘subluxation;’ however, they simply want to rename it (e.g., ‘segmental spinal dysfunction’). The same is true of many of our American chiropractor, sublux deniers.

    What is in a name? A skunk by any other name would smell as nasty. (Apologies to my friend, Bill Shakespeare. Yes, I know him. His PhD adviser was thrilled to be primary author on an article with W. Shakespeare.)

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