It’s frustrating to read yet another story of the process of developing a potential new medical treatment derailed by the current infrastructure of quackery that we have in this and other countries. This is one of the unmeasurable harms that results when pseudoscience is given regulatory, academic, and professional legitimacy. The press then celebrates the nonsense that results.
The basic story is often the same, with a few variations. First, however, let me describe what should happen when someone comes up with an idea for a new medical treatment.
Background research – The first step, whether the innovator is within or without the medical community, is to familiarize oneself with existing research. Is the idea plausible, has it been investigated before, are there any similar treatments that can act as a guide to predicting how this new treatment will work?
There is no satisfaction in hanging a man who does not object to it.
~ George Bernard Shaw
I work in a 5-hospital system and many of us practice at several hospitals. The residents rotate through at least three of the hospitals and the peripatetic nature of health care allows word of curious cases to percolate through the system. My current resident mentioned that there was a case of a vertebral artery dissection in a young female shortly after chiropractic neck manipulation.
Man, that’s awful. Is she doing OK?
Evidently there were no permanent neurologic sequelae. She dodged that bullet. Or perhaps that noose, as I once calculated that the force of a neck crack is about 40% that of hanging by the neck and it has the same pathologic changes if it goes wrong. Every time I see a death in the movie where the neck is twisted to break it, I think chiropractic, although some tolerate it better than others.
I have not written on CNS events related to chiropractic since 2008, although the topic has been covered by Dr. Hall. I still suspect that occasionally there is a perfect storm of bad luck, the forces are perfectly aligned in a susceptible patient and they get an embolic stroke or a vertebral artery tear.
If the “Health Freedom” movement has its way, everyone in the United States will be able to practice medicine. It may be quack medicine but that doesn’t seem to bother them. Short of that, chiropractors, naturopaths and acupuncturists are aiming to reinvent themselves primary care providers and even physicians. As David Gorski pointed out, this will reduce medical doctors to just another iteration of physician, the “allopathic” type, equal in stature to the chiropractic, naturopathic and acupuncture types. These “physicians” already call themselves “doctor” (e.g., “Doctor of Oriental Medicine”) and claim to graduate from four-year “doctoral” programs. This despite the fact that their schools operate outside the mainstream American university system and avoid some of the basics of typical graduate programs, such as entrance exams, as well as the extensive clinical training required for medical doctors.
Consumers are confused by all of this, and who wouldn’t be? In 2008 and 2010, surveys done for the American Medical Association by outside firms revealed that many patients did not know the qualifications of their healthcare provider. The comparisons were between allied health professions (e.g., audiologists and nurse practitioners) and medical doctors, but chiropractors were included. In 2008, 38 per cent of those surveyed (n=850) thought chiropractors were medical doctors, although that dropped to 31 per cent in 2010. Still, we are talking about roughly one-third of the survey participants.
The surveys also asked about the use of the term “physician” and confusion in advertising materials.
People are sometimes surprised to learn that all the heavy hitters of alternative medicine, such as acupuncture, chiropractic, homeopathy, etc., are inflicted on animals as well as humans. I’ve written about veterinary homeopathy, and the associated manufactroversy, in a previous post, and today I thought I’d take a look at veterinary chiropractic.
In most states, chiropractic is defined in terms of treatment of humans and chiropractors are thereby licensed only to treat humans. However, there are a variety of ways around this for people who want to subject their animals to this therapy. Some chiropractors will simply treat animals and ignore the fact that it isn’t technically legal for them to do so. And some veterinarians will take one of the many training courses available in animal chiropractic and then employ it as part of their practice of veterinary medicine. A previous SBM article has discussed the lack of consistency or legitimate scientific content in most of these courses.
As a pediatrician caring for hospitalized children, I deal with fear on a daily basis. My day is saturated with it. I encounter fear in a variety of presentations, with parental fear the most obvious but probably least impactful on my management decisions. I do spend a lot of time and mental energy calming the fears of others but more managing my own, both struggling to prevent it from biasing my thought process and harnessing it as a productive motivational force. I devote a significant amount of effort towards teaching residents and students the practice of inpatient pediatric medicine and fear can be a valuable teaching tool when used appropriately.
So I admit that I take advantage of fear to a certain extent in my practice. Most pediatricians do. Maybe we all do. Proper informed consent, for instance, must include potential poor health outcomes related to medical intervention or the refusal of them. I accept that fear is an impetus for seeking medical care. Parents should be afraid of poor health outcomes from vaccine-preventable illnesses, for example. They should be made aware of the repercussions of poor adherence to home asthma management or of not placing their child in a proper car seat every time they put them in a car. Fear can serve the greater good.
But there is a difference between these unavoidable aspects of science-based medical care and the abuse of fear by practitioners of irregular medicine.
Via the magic of legislative alchemy, chiropractors are already licensed health care providers in all 50 states. Thus their legislative efforts tend to focus on expanding their scope of practice and forcing public and private insurers to cover their services, in some cases at the same rate as medical doctors. Those efforts continue in 2013 with 65 bills impacting chiropractors introduced so far. Of those including substantive provisions (as opposed to, say, simply raising fees), only one is not to their advantage.
New Mexico chiropractors are once again attempting expansion of their scope of practice. In 2008 and 2009, the New Mexico legislature created a new iteration of chiropractor, called “the certified advanced practice chiropractic physician.” A certain faction of the chiropractic industry is attempting to rebrand chiropractors nationwide as primary care physicians and this was a signature event in those efforts. With 90 hours of additional education, these advanced practice chiropractors can administer a bevy of dubious remedies, such as bioidentical hormones.
The new law also permitted prescription of dangerous drugs and controlled substances and administration of drugs by injection, but only if on a formulary approved by the state pharmacy and medical boards. The chiropractic board didn’t like having to get approval from pharmacists and medical doctors, so they went ahead and added what they wanted to the formulary, ignoring the other boards despite their own attorney’s advice that they couldn’t do this. This got them into a couple of court battles with the pharmacy and medical boards. The International Association of Chiropractors (ICA), the traditional, subluxation-only chiropractic faction, jumped into the fray to oppose this power grab. The ICA believes chiropractic should remain drug and surgery free.
Chiropractors are trying to rebrand themselves as primary care physicians, a topic both Harriet Hall and I have addressed (here and here) on SBM. Toward this end, they are seeking the expansion of their scope of practice, via the magic of legislative alchemy, to include the prescription and administration of drugs. Not drugs that any self-respecting M.D. would use, but drugs nonetheless. That effort succeeded to an extent in New Mexico. Recently Colorado got into the act. Other states have followed suit.
Chiropractors have claimed from the very beginning they are primary care physicians. Chiropractic was born in 1895 with the notion that virtually all diseases could be resolved with chiropractic treatment. This was Daniel David Palmer’s original contention, that the interruption of “nerve flow” by “subluxations” caused disease which could be remedied by spinal adjustment to restore the flow, thereby allowing the body to heal itself.
State chiropractic practice acts have always given chiropractors a broad scope of practice which allows them to diagnose and treat virtually any condition as long as they can squeeze the treatment into the “chiropractic paradigm.” If they can pretend the condition is amenable to chiropractic treatment via the detection and correction of subluxations, they can diagnose and treat it legally. This is how they are able to claim, falsely, that asthma, allergies, colic, and many other health problems can be resolved by chiropractic care. This is how “straight” chiropractors still practice.
I quite like Portlandia. I find it funny and it captures a part of Portland. I recognize large swaths of the city’s culture in the show. Other representations of the city I recognize less. Sunset publishes beautiful photographs of the NW, but when I look at the photos I think, that section of the city never looks that good. It is quite wonderful how Photoshop can improve on reality.
Like most major cities, Portland has a monthly magazine, Portland Monthly. The city represented in that magazine is mostly alien to me. I look at the advertisement, the articles, the photographs, and wonder when did Portland become a city with an average 7 figure income? The Portland in which I grew up and currently live is rarely found in the pages of Portland Monthly. If you are extremely well to do, I suppose you are in the demographic Portland Monthly. But when I flip through the pages of the magazine, I see little I recognize, but I have never completely abandoned the hippie/grunge aesthetic of my younger days.
Every January they have the best Doctors issue* and this year, for the first time, they offer The Portland Alternative Medicine Guide. Well, less a guide and more an extended infomercial filled with ‘facts’ that deserve the quotes. (more…)
Andrew Weil, MD, pops up quite frequently on SBM, most recently in this entry by Harriet Hall, so I will not spend much space introducing him. An excellent biography and critique of Dr. Weil was written by Arnold Relman, former Editor of the New England Journal of Medicine. It is over a decade old, but contemporary to some of the events described in this post, and still quite relevant.
Suffice it to say that Dr. Weil is one of the most successful and well recognized popularizers of alternative medicine. He has authored or coauthored dozens of books. His website sells everything from baby pacifiers to vitamins to breakfast sausages, packaged bearing his name and/or visage. He is an altmed rockstar. He has been a key player in the branding of alternative medicine. In particular, been an advocate of “integration” of traditional and alternative medicine. He has created and exported residency training programs, and more recently proposed board certification in integrative medicine.
I recently read a book entitled On Being Certain: Believing you are right, even when you’re not, by Robert Burton, nicely-reviewed and recommended by Harriet Hall. In his book Dr. Burton excerpted an interview with Dr. Andrew Weil, pointing out Dr. Weil’s profound certainty about the effectiveness of a particular alternative treatment in spite of contradictory evidence. Dr. Hall also discussed this section of the book in her review. I found the excerpts fascinating and decided to delve more deeply into the interview. I also found another interview with Dr. Weil relevant to his ideas about evidence.
I can think of few conditions with clinical features more ideal for establishing a pattern of abuse at the hands of practitioners of so-called alternative medicine than Tourette syndrome. Tourette syndrome (TS), which first manifests itself in early childhood in the overwhelming majority of patients, is a neurological disorder with infamous motor and vocal manifestations and a troubled past. Historically the condition was blamed on everything from emotional disturbances to outright faking to demon possession. But over the past few decades it has increasingly been recognized as a primarily organic disorder caused by negative genetic and environmental influences on areas in the brain which control movement and behavior.
I have a particular interest in Tourette syndrome, not just because I am a pediatrician but because I was diagnosed with the disorder at the age of seven. I have been lucky in that my symptoms, after a few rocky years in middle school and early high school, have been fairly mild. It is obvious to most people that I have a movement disorder, but it has never impacted my ability to function in society and succeed in my chosen profession of pediatric medicine. In fact, I often think of my Tourette’s as a positive aspect of my life, believing that it helped shape who I am as a person. I feel that it has helped instill in me positive personality attributes that are beneficial in the practice of medicine, such as empathy and compassion.
Patients that would have been institutionalized a hundred years ago, or worse as you go farther back in time, are now treated based on scientific advances in neuroscience and pharmacology, typically very successfully — that is if they manage to avoid involvement with quacks and charlatans. A 2009 survey of TS patients, or parents of patients with TS, revealed that nearly two thirds partake in alternative therapies with no proven benefit.