Friday, July 31, 2009

Talent is Long Patience

Photography has been a hobby of mine since my dad took money I saved for a Minox (a spy camera) and instead bought me an Exacta 35mm SLR camera. I was very disappointed that he got that camera. However, the disappointment went away as I fell in love with 35 mm photography. Back then I developed and printed my own B&W film. To see some of my photography (a few go back to when I got that Exacta in 1972) check out my photoblog Perle's Vision.
BTW Exacta invented the penta prism which allows one to look thought the eyepiece of the standard SLR and see the image right side up. That's the bump on the top of a SLR.
I bring this up because I get a lot of different photography newsletters and one lead me to a photographer's web site and a discussion about the myth of talent. On that page I found this quote:
“Talent is long patience.” – Gustave Flaubert (writer of Madame Bovary)
This resonated with me because of something I've always remembered from late M. Scott Peck's book, The Road Less Traveled. There's a part of the book where Dr. Peck discusses his complete and total lack of mechanical aptitude, talent if you will.

One day he walks up to a neighbor who is taking apart a lawn mower. Peck expresses his astonishment that his neighbor can do this. He writes that his neighbor looked up and with the wisdom of Job says, "Scott, your problem is you don't take the time." To which Peck writes how angry he was because he knew the problem was a lack of talent.

Sometime later a female patient (Peck was a psychiatrist) returns to his office complaining that she can't release the parking brake on her car and expects that Dr. Peck, as a male, will be able to assist. So he goes out to see the car and decides to take his neighbor's advice. So he gets under the dashboard and gets comfortable (how is that possible?). Looking around he describes what he sees and I knew it was the kind of parking break where there is a peddle one pushes to set the break and a handle one pulls on to release it. Scott sees the pin that is holding the ratcheting peddle and releases the pin.

What I learned from this is that aptitude, ability or call it talent is often the patience to continue to learn some skill or art or...

I have seen this in my students over the years. Some pick up the skill to perform a manipulation easily. Typically they are athletes and thus already have, though patience gained, a large body of psychomotor skills. They are the uncommon and lucky few.

There are those then who do not pick up the skill quickly. I have found that these people then self select into two groups. One group lacks the "long patience" and gives up. These people often never get very good at the skills we teach. I call these people the quitters.

In the 1990s when I was first at the University of Bridgeport I would do locum tenens (cover another doctor's practice while they were on vacation). I was in this one doctor's office where the first patient I adjusted made a sound of surprise. I was surprised myself thinking I hurt the patient. Instead they said that they were shocked that the manipulation did not hurt. They said that usually it took their regular doctor multiple tries to adjust their neck (the doctor and the patients had this erroneous idea that manipulation is only successful if accompanied by a popping noise). I said I was lucky, one does not want to embarrass the doc one is covering for. However, almost every patient I performed a manipulation on said the same thing to me. I came to realize that this doctor couldn't properly perform a manipulation after 10 years more of practice than I had. The amazing thing is patients still went to him shows how poor patients are at picking good doctors. I figure a good chiropractor has good hands, good mind and a good heart. I hope at least he had the other two.

The final group of students are those who do not pick up the skills easily but persist in their attempts to acquire the skill - they have Flaubert's "long patience". I know this path because as a student at The Texas Chiropractic College, starting in 1979, I persisted for almost a semester and a half of not being able to perform a manipulation until the break through came for me. I had made a different decision than the quitters. I thought if HE (my teacher) could do it, then so can I. Never really one with considerable athletic ability I learned that persistence was the key. But one must have patience to persist through times of poor performance (and as a child ridicule for air balls in basketball and missed pop flies etc.).

Last year, I had a student, a few months from graduation, lament an unacceptable skill level at some manipulative procedures we teach at UBCC. I told the student that this was a good thing and I was pleased to hear how much this distressed the student. The student was shocked that I'd say that. I continued, the fact that the student was greatly distressed by the lack of skill means that unlike that doctor I did locum for, the student's distress would motivate attempts at improvement.

I think life should be process where by we are continually improving and trying to get more talented with the long patience of trying to do better. And no I'm not yet happy with my skills and knowledge as a doctor, teacher, friend, father, husband or even photographer, and that's a really good thing!


A couple of other articles on the need to practice

Secrets of Greatness
The Expert Mind

Thursday, July 30, 2009

Preventing vs. Postponing - will health care reform save money

I'd love to say that the what you'll read below, about how health care reform, specifically preventive health care, is my work. It is not. It comes with permission from a friend, colleague and brilliant chiropractor.

Previously I posted a note that suggested that the Congressional Budget Office (CBO) will be the linchpin in health care reform. That Office will be required to calculate the budget implications of any reform package. And if that calculation reveals that the reform is underfunded by about a trillion dollars (as it is right now) this will create insurmountable problems to its passage.

Nervous congressional Democrats are trying to figure out how to circumvent the CBO. One strategy is to bypass the CBO and rely on the administrations calculations from their Office of Management and Budget, a sort of parallel organization to the CBO, the difference being that the CBO can be relied up to come up with whatever number is needed to pass the legislation. One of the areas of contention between the CBO and the OMB is how much to credit preventive care as a money saving element of reform. The CBO credits it with zero dollars and the OMB with hundreds of billions of dollars. Here’s a news item from yesterday that highlights this:
Sen. Barbara Boxer said she would not feel obliged to abide by CBO’s work if it does not take into account savings from preventive healthcare and other reforms.
"I haven’t seen [the CBO score] but if they don’t take into account prevention, I certainly won’t. I will not follow it — we just heard from the CEO of Safeway, who said his insurance costs went steadily down since they instigated incentives for prevention.

Any scoring that doesn’t understand that, is not relevant to the way we work.”
Who’s right, the CBO (zero savings from prevention) or the OMB (hundreds of billions saved from prevention)? The CBO is correct (zero savings). Here’s why—

It is endlessly repeated by politicians, public health advocates, physicians, TV talking heads that we spend a huge percentage (the figure 30%) is often used to treat “preventable” illness. What is usually meant by this are those chronic diseases that are driven by lifestyle—diabetes, heart disease, COPD, smoking-related cancers etc. This is undeniable. This set of conditions easily accounts for at least 30% of our health care budget. There is in fact an exploding industry devoted to both the primary and secondary prevention of these problems, the so-called Disease Management and Wellness industry. These programs target the high risk population and attempt (with varying degrees of success) to change behavior and thereby reduce health care costs. It can be shown that well engineered and properly implemented programs of this type can indeed pay for themselves and even return savings in the form of reduced health care costs. So what’s the problem? If a company of, say, 500 employees can do this, why can’t be implement this on a scale of the entire US population?

Here’s the problem. If I’m an employer considering such a program one of the questions I have to ask is, “Will I, as the employer, realize the savings from such a program? So what if I spend money to get an employee to quit smoking and then he leaves this job to work somewhere else…I’ve just financed the savings for some other company.

And indeed if a particular company has a high employee turnover rate these programs will not save money. The reduced health care expenditures have to occur under the watch of the employer who paid for the program for this to make sense. There are algorithms that will tell you if a particular employee turn-over rate will or will not allow for such savings. From the employers perspective the healthy employee has to remain in his employ to realize the savings. The key word here is “perspective.” We must always ask from whose perspective are we calculating health care costs or savings.

When doing the calculations that the OMB and CBO are doing the correct perspective from which to view this is the societal perspective. We are interested in the total net costs or savings in our entire health care system for all persons at all stages of their life. An individual might leave and employer but he never leaves the umbrella of the societal perspective.

Ah, but this is good news, you might think. Any ex-smoker, reformed couch potato or otherwise newly healthy person is always under the societal umbrella and thus all savings will eventually accrue at a societal level. Ergo, we save billions.

But this societal perspective is precisely the problem. Let’s consider several scenarios from both the employer’s perspective and from the societal perspective:

Scenario 1. Joe Blow is a 32-year old smoker who works for the Megatron Corp. Joe says the hell with it. I like cigarettes. I’m not quitting. Joe stays with Megatron his whole career. He experiences a variety of smoking-related illnesses (chronic bronchitis) and eventually dies of lung cancer at age 59. The Megatron Corp. spends a good deal on money on Joe’s health care over the years and eventually pays for the the futile treatment of his lung cancer.

Scenario 2. The Megatron Corp. implements a worksite wellness program that includes a tobacco cessation program. After couple of failed attempts Joe eventually quits smoking at age 36 and continues to work productively for Megatron Corp until he retires at age 62. During his employment Joe enjoyed generally good health and had only routine medical care with the exception of knee surgery to repair the ligaments he tore skiing. (Joe really did reform himself…he became an avid outdoorsman, hiker, skier.) The couple of hundred dollars Megatron spent to get Joe to quit smoking saved many tens of thousand of dollars in related health care costs.

Success!! Prevention works. It saves money. At least from the employer’s perspective. But from a societal perspective Joe’s story continues:

Joe enters retirement (and Medicare) in good health. He remains active, but eventually that repaired knee gets worn out and he gets a total knee replacement. By his mid-70s one of his hips is gone and that gets replaced too. But Joe is still going strong. Soon he needs cataract surgery and some lens implants as well. Joe is becoming all spare parts!! In his late 70’s he suffers a mild stroke…his skiing days are over. Two years later he’s diagnosed with colon cancer. Surgery and radiation go pretty well, but one never knows.

What finally gets him, though, is dementia. After a few years his children realize that Joe can no longer care for himself and his children put him in a long-term care facility. He doesn’t last long there, only 3 years, an Joe dies at age 83. Not that anyone is keeping track, but Medicare ended up spending $400k on Joe during his retirement.

Alright, this is all make-believe, but what this illustrates is this: From a societal perspective, prevention of chronic illness is impossible. All that is possible is to postpone chronic illness. Every case of lung cancer that is prevented exposes society to future cases of colon cancer, stroke, Parkinsonism, dementia, and well, everything else. Every premature diabetes-related death that is prevented exposes society to future cases of breast cancer, skin cancer, kidney failure, liver disease, and well, everything else.

Now of course, if we can prevent lung cancer and diabetes and emphysema and other chronic disease, we should. This is the point, after all. But we cannot do so with the illusion that somehow we will never end up spending boat-loads of money as we age and become infirm. In nearly all cases, preventing early chronic illness will end up costing us far more money to treat later-life chronic illness. But that’s the price of success.

Anyway, watch for the battle between CBO (who are professionals) and the OMB (who are political hacks) on this.


As one who teaches a class in wellness, I certainly thought that prevention saved money. As you can see from what my colleague has written, it all depends upon the perspective of who pays for the prevention on who saves money. Obviously, preventive measures that are effective: proper diet, regular exercise, no smoking, use of seat belts, safe sex, should be implemented.

I often hear people say we all have to die sometime. In fact, someone trying to get me to buy tobacco in Mexico a couple of weeks ago said that to me. But the reduced disability, prolonged and productive life is good for each of us, no?

Frankly, my mother’s death at age 66 from cigarette smoking deprived my children of a grandmother. I was very fortunate that my own grandmother and great grandmother died when they were in their late 90s and early 100s, respectively. I miss them both but have vivid memories as they both died when I was an adult. My children don’t have that. Likewise, my mother’s early death meant she didn’t see my daughters grow to become a bat mitzvah, let alone married and have children.

Thus, I think the benefits outweigh the economic cost and we do need to implement more and better prevention programs. If it takes the deep pocket of the government to do it so be it but let's be honest about the costs unless do we really need a white lie is needed to get the reform package passed.


Saturday, July 25, 2009

Cultural Authority and the Chiropractic Profession

Cultural authority: an editorial by John M Ventura, DC

In the excellent text, Surviving in Health Care by Dieter Enzman, MD, (Mosby, 1997) a working definition of cultural authority is proposed, and more importantly, a strategy for achieving cultural authority is outlined.

The ability of medicine to achieve cultural authority in the early 1900s was a “confluence of factors encompassing professionalism, the Industrial Age and an incentive-skewed market.” What may be most remarkable, given the almost exponential growth of health care costs through the 20th century, was the duration that medical cultural authority went unchecked. Medicine was said to have achieved “professional sovereignty.” Whether consequential to, or simply a reflection of, the constraints of managed care, medicine has lost some of its authority. Dr Enzman’s book is an effort to place medicine back on a path to achieving a new measure of cultural authority. The relevance for the chiropractic profession is that cultural authority is defined in a manner which may be pragmatically applied, and Dr Enzman has a lot to teach the chiropractic profession with his recommendations to the medical profession. If and when the chiropractic profession takes on this challenge may be the determining factor between merely surviving into the 21st century versus thriving. Our future is not guaranteed. A collective effort of well thought out strategies will be needed to implement the requirements for achieving cultural authority.

Cultural authority allows a profession to define its own professional truth. The profession decides what is fact and what is fiction and the public accepts the rules set forth. Cultural authority is characteristically unique in “having authority without having to overtly exercise it” as opposed to social authority, which is the ability to command people. There are two primary features of cultural authority: competency and legitimacy. Competency is a demonstration of technical expertise. Legitimacy is achieved by using competency to advance public health.

Competency requires validation by peers and rational foundation (scientific basis). A key feature of this technical expertise is that competency must be gained as a group - not individually. The beginning of shared professional competency for medicine was achieved by standardized training, based upon the principles of science. An intended benefit of professional competency is that when any individual member of a profession gives advice, that advice is representative of “shared professional standards”, not the idiosyncratic recommendations of a renegade practitioner. Professional legitimacy includes collegiality, cognitive approach, moral attributes. You be the judge of how well the chiropractic profession has demonstrated collegiality, a cognitive approach to health issues and high moral attributes.

If we can agree that achieving cultural authority is in the best interests of the chiropractic profession (the ability to define our own professional truth), then we might ask what steps the chiropractic profession can take to achieve some measure of cultural authority? As was the case for medicine, chiropractors need to demonstrate competency and legitimacy to the public. And this must be done by the collective efforts of the entire profession.

Dr Enzman describes the following for the medical profession to regain some its lost cultural authority:
  • Continually demonstrate competency to the public; proof of training and licensing is no longer sufficient
  • Provide ‘credible data’ to validate medical claims and recommendations
  • Focus upon outcome analysis, a ‘crucial’ factor for the medical profession
  • Standardization of practice patterns, both regionally and within each specialty
  • Standardize the lexicon, which demonstrate peer validation of competency
  • Focus upon the societal value of health, not upon reimbursement
  • Avoid ‘filtering and restricting information available to patients’; embrace the informed consumer(patient)
  • Be leaders and therefore, be honest, at all times
There is a theme that surfaces in the above recommendations of Dr Enzman – patient centered, evidence based care. Patient centered, evidence based care needs to be the mantra of the chiropractic profession. The following represents a partial list of the steps necessary to place the chiropractic profession on the road towards cultural authority:
  • Standardize the training of chiropractors using principles of science, best available evidence, and consensus (though the consensus must be based upon the previous two attributes).
  • Raise the standards for admission to and graduation from chiropractic colleges, and raise the standards for licensing
  • Standardize the chiropractic lexicon
  • Affiliate chiropractic colleges with established and proven universities so that resources (faculty, research facilities, etc.) can be shared
  • Define the most fundamental aspects of chiropractic care: subluxation (in a quantifiable, testable manner); treatment frequency and duration for given clinical presentations;
  • Standardize clinical outcome measures to validate responses to chiropractic care (“credible data”)
  • Increase funding towards chiropractic research
  • Encourage attendance at research symposiums
  • Professional unity: one primary organization to represent the profession politically; all chiropractic colleges embrace and implement collectively determined standards of care;
  • Patient centered, evidence based care is the foundation for training of chiropractors
  • Reduce variation of approaches to diagnosis and treatment within the profession
  • Increase training in all manner of public health issues for chiropractors
  • Encourage chiropractors to become involved with APHA
The public perception of the chiropractic profession, by and large, is not one of trust. In 1990, the McLean County (Illinois) Chamber of Commerce's Professional Committee surveyed a population of people (12% of which were chiropractic patients) with the following results: only stockbrokers scored lower on a scale of trustworthiness than chiropractors, over 45% of those surveyed felt chiropractic ethics were below average. In the Canada Speaks survey, held in 2002 and again in 2006, chiropractic trustworthiness improved from 15th place to 12th place (49% of those surveyed felt chiropractors to be trustworthy), but still well below medical physicians(80%) and nurses(87%). Clear demonstrations of competency and legitimacy, by the profession as a whole, are required to increase public trust, and therefore, increase the cultural authority of the chiropractic profession.

Chiropractic Business - What is the nature of the business

A few friends of mine sent me a great book to read by Jeff Jarvis, What would Google do. There is a chapter in the book that talks about what is the nature of your business and how most people don't know what business they are in.

Approximately 25 years ago a NYRR volunteer (non-medical) I was friendly with explained this concept to me. He worked in fleet rentals for Hertz and asked me what business is Hertz in? The obvious answer, which I said, was renting cars. He told me I was wrong. Renting cars wasn't a profitable business. The cost of advertising, reservation system, rental counters at airports, buses, lots, carrying charges on the cars and their maintenance was barely offset by the actual money received for the rentals. Thus, one can't really say that Hertz was in the car rental business.

He said that what Hertz did was the largest manufacturer and seller of used cars. That was because they sold the used car for more money than they bought the new car for but couldn't do this until it was used "enough." Those of us who rented from Hertz actually paid for the privilege of working to turn the new car into a used enough car so that Hertz could sell the used car we made back to us for a profit.

He used this as a metaphor for his belief that most companies have no idea what business they are in. This made me think about what business I, a practicing chiropractor was in.

As I said I was reminded of this by Jeff Jarvis' book WWGD. The question then is what business is a chiropractor in? Some in my profession would say that we are in the subluxation removal business. This is delusional. How many people who have never heard of chiropractic wake up and say, "gee I wish there was someone who could get rid of these darn subluxation." The obvious answer is no one. Now that could of course be because they didn't know the word. However, there isn't a vernacular term for the subluxation as is true with other medical conditions. People say that someone broke a bone, and might not know the term fracture. Or they'll know heart attack or stroke rather than myocardial infarction or cerebral infarction.

Some of my colleagues would say, but a person dying of heart disease, of cancer or diabetes or... does not know that they have these diseases until they become symptomatic. That is true. However, at this point in time my profession, chiropractic, has yet to find a valid or even reliable way to find a subluxation. Nor have we found that getting rid of them helps people or that a person with a subluxation is less healthy then a person without one.

On the other had there are valid and reliable tests for heart disease, cancers and diabetes. We also have good evidence that left untreated these diseases do kill and that with treatment patients can sometimes live much longer lives (depending on the specific disease, the stage at diagnosis).

Clearly there is good scientific evidence that spinal manipulation is a beneficial intervention. While the physical therapy profession and others have newly discovered the benefits of manipulation, after years of saying it was quackery, those benefits are found without the metaphysical aspects of the subluxation dogma some in chiropractic espouse.

Then what is a chiropractic business? Generally it is non-surgical spine care or another way to think of mainstream chiropractic is it is the non-surgical management of spinal pain disorders.

I say management because that might mean that chiropractor does all the diagnosis and treatment or it might involve an integrated approach where the doctor of chiropractic works to lead a team or be a member of a team whose goal is the improvement in a patient's spinal function.

Do chiropractors' management skills extend beyond the spine? Depending on the doctor the answer is yes. My own practice in NYC in the 1980s was mostly lower extremity conditions as most of my patients were runners. But I also treated a lot of cyclists, swimmers and triathletes so also saw a lot of upper extremity problems too. I was a sports chiropractor and thus had competency that extended beyond the spine.

Some of my peers think because I was a co-author on a paper titled: Chiropractic as spine care: a model for the profession that my co-authors and I believe that chiropractic has no place outside the spine. This is very far from the facts of our paper. We just believe that as a profession all of us need to, at minimum, be competent in non-surgical spine care and the profession needs to maintain the spine and its non-surgical care as the basic minimum competency. And come on when the public thinks of a chiropractor what do they think of? SPINE. I travel a lot and when people find out I'm a chiropractor they either grab their neck or the their back and say can you help me. No one has ever said - "oh I have a subluxation." That is despite the fact that so many chiropractors talk subluxation 24/7 even on the web.

An analogy. My family has had two occasions to consult oral surgeons. These doctors are trained as dentists. However, they do not have additional professional training at medical doctors. These dentists do not fill any cavities, or do other restorations that we ordinarily associate with dentists. Yet they are dentists. But the American Dental Association does not market dentistry as oral surgery. Still while these oral surgeons do not have training as medical doctors they do have additional training beyond what a general dentist has.

Likewise, for a chiropractor, such as myself, specializing in sports chiropractic there is the need for post-graduate training without that then the general chiropractic physician is a non-surgical spine specialist. Not a bad business to be in when over 90% of people will get back pain sometime in their life.


Thursday, July 23, 2009

Two views of chiropractic

The Chicago Tribune published a story about chiropractic today which shows the dichotomy within the profession and they have squarely come down on the side of the evidence based approach to chiropractic. They quote Dr. Don Murphy with whom I co-authored a paper on making chiropractic more mainstream using podiatry as a model. (1)

They also have suggestions on picking a chiropractor:
  • Be wary of those who say spinal manipulation can cure whatever ails you
  • Ask whether exercise is part of the program.
  • Ask friends and relatives for recommendations.
  • Get more than an adjustment
  • Shop around
I've blogged on choosing a good chiropractor before. I agree with the recommendations that Trib wrote except for getting a recommendation. It is obvious that there are people who have become indoctrinated by the quasi-metaphysical, pseudoreligious, pseudoscientific branch of the chiropractic profession. These people have been trained that spinal manipulation will have some profound affect upon their overall wellness above and beyond the function of the spine, other joints or the musculoskeletal system.


1. Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropr Osteopat. 2008 Aug 29;16(1):10. (this is a free full text paper just click on the link)

Malpractice 2

In a recent blog I commented on a NY Times op-ed on malpractice, Liability = Responsibility. The author, Tom Baker based this on a paper from the NEJM by Studdert et al (1) Studdert et al analyzed 1452 closed malpractice claims from 5 malpractice companies. They used an expert panel to determine if for each claim if there was an injury and if it was due to error.

We have heard for years Republicans and other conservatives bleating on and on that the problem with malpractice is frivolous suits. Well these researchers found that only 3% of all the claims involved plaintiffs without any injury. These are frivolous suits.

Of the 97% of closed malpractice claims with an injury, 37% were deemed to not have been caused by physician error and 28% resulted in payment. Based on total amount paid on these cases and legal costs in all the cases where there wasn't an injury or error Studdert et al determined that 13% (excluding close calls on determination of error) to 16% (including close calls) of the total costs of these 1452 malpractice claims involve cases that might be removed from the system with some kind medical malpractice reform. Thus, reform would not result in substantial savings.

On the other side of the coin 27% of cases where an error occurred did not result in any payment to the plaintiff (which is almost equal to the percent of cases with no error that resulted in payment to the plaintiff). Thus in this study 236 (16%) people who were injured due to medical error received no compensation and 151(10%) received compensation when they shouldn't because there wasn't an injury or their injury wasn't due to a medical error. Thus, the correct outcome (payment or no-payment) occurred in 3/4 of all cases reviewed.

I think the real problem is that we have a fault based system. If we switched to no a fault system with universal health care we would be better off.

As a no fault system providers would willingly share what occurred that resulted in the injury. This would allow others to learn from the mistake. This is how the aviation industry works. A pilot or air traffic controller that reveals an error, regardless of the outcome (e.g. a crash or no harm) won't be disciplined if they disclose the error within a short time (I believe it is 2 days). Thus, everyone can learn what went wrong. Right now errors are discussed in private conferences in hospitals but not disseminated widely for everyone to learn from.

Secondly if we had universal health care then people wouldn't have to sue to get money to pay for their care after they were injured. Studdert et al found that it took the average claim five years to be closed. That's a long time for someone to wait to get money to cover their medical expenses injured due to an injury that was due to medical error.

We need change in the malpractice system but it should be based upon a knowledge of what's wrong rather than people's biases which all I have heard until now.


1. Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006 May 11;354(19):2024-33.

Sunday, July 19, 2009

Rationing Health Care

The 3rd rail in the discussion about health care reform is rationing. Princeton ethics professor Peter Singer presents a cogent argument for the need for rationing in a NY Times Magazine article, Why We Must Ration Health Care.

I won't rehash his arguments except to say that though the use of a joke about prostitution he notes that this is all about a negotiation about how much we will spend for a particular outcome. Britain’s National Institute for Health and Clinical Excellence (NICE) which I have blogged about earlier regarding treating low back pain. NICE has said that for a year of extra life they suggest spending up to approximately 49 thousand dollars. I know this seems harsh but as I said it is about a negotiation. Most would agree that 10 million dollars is too much for our economy to pay to extend a life one year. Obviously, Bill Gates or others will limitless finances are free to do that but clearly no country can afford to spend that much money for only 1 year of life. Everyone would agree that spending $100 to extend a life one year is easily worth it. So the difference between these two are just a matter of negotiation.

One fact that Singer ends with is a refutation of the conservative argument that health care reform will result in the US getting stuck with health care that the Britons or Canadians have, as if that is a horrid outcome. Singer presents the results of a Gallup poll on how happy are US, UK and Canadian citizens with their health care. Seems that if this poll is definitive, we in the US would be fine with a UK or Canadian style of health care, not that those are the only models to choose from. I guess the conservatives hope that we'll just listen to their fallacious arguments and believe them. Fear mongering is a live and well on the right.

Details on the Gallup poll can be found here.


Friday, July 17, 2009


In the NYTimes (what else?) there is an interesting op-ed about malpractice, Liability = Responsibility. Knock on wood I've never been sued but I have taught risk management for a few years and have been a consultant for some malpractice cases so the issue has more than a casual interest to me. The article cites a paper from NEJM that is a study of malpractice cases which is very enlightening.

To put it simply the problem which has created the "malpractice crisis" in the US isn't those nasty litigators, it is negligent doctoring. It seems that the vast majority of malpractice cases the doctor involved actually treated the patient in a negligent way. So the cure for the malpractice crisis is better doctoring which the Times op-ed piece suggests means evidence based practice.

Then again when one looks at how low chiropractic malpractice insurance costs one understands that such events are extremely rare in chiropractic. I think most people are shocked to find out how little chiropractors pay for malpractice, I know that every MD I have spoken to about the amount has envy. Most chiropractors pay a few thousand dollars for the same malpractice coverage that MDs pay tens to hundreds of thousand dollars in premiums.


Monday, July 13, 2009

Chiropractic In the News Downunder

The Australian TV show Lateline recently did a piece on chiropractic. This was motivated by the British Chiropractic Association's libel law suit against Simon Singh. On balance I think this was pretty good news story. From when I began in the profession, in 1979, as a student at Texas Chiropractic College and for a long time after that it seemed to me that the media were just hatcht men for the AMA. Since Judge Getzendanner's 1988 decision in the Wilk v. AMA law suit the media has been kinder.

The Lateline video includes interviews with Bruce Walker, DC, MPH, DrPH. and Chris Maher, PhD. Dr. Walker is the editor in chief of Chiropractic and Osteopathy an open access, peer-reviewed online journal that aims to provide chiropractors, osteopaths and related health professionals with clinically relevant, evidence-based information. I am an one of four associate editors for C&O. So often it seems that print or video media edit away the substance of a interviewee. I think Dr. Walker's interview was treated fairly and he gets across his point about the evidence regarding chiropractic care.

Dr. Walker notes that chiropractic care should primarily be for the musculoskeletal system. In C&O I am a co-author of a couple of papers that suggest that chiropractors should mostly be non-surgical spine specialists because substantially what we do is spine care.

Dr. Maher, who is a physical therapist discusses recent research that found that manipulation is no better than standard medical care. Unfortunately his use of the term manipulation is unusual. Only 5% of the subjects in this study actually had manipulation and the rest had mobilization as a treatment. Thus the study does not actually evaluate spinal manipulation. with Dr. Jeff Hebert of the U of Utah, I have published a letter to the editor pointing out this inconsistency.

There is also an interview with an MD about stroke in which he again ignores the most recent research showing that manipulation does not cause stroke.


Friday, July 10, 2009

Foundation for Anachronistic Chiropractic Pseudo-Religion

A friend recently sent me an email from the Foundation for Vertebral Subluxation (FVS). They say that they are: "Dedicated to the Founding Principles & Tenets of the Chiropractic Profession"

This is an attempt to revise the history of chiropractic to suggest that there was stagnate set of principles the some people today are trying to change. The founder of chiropractic, D.D. Palmer changed his theory about what chiropractic was three times over the seven years he wrote about chiropractic. (1) Some outside chiropractic like to point out that D.D. wasn't an M.D. or university educated. This is absolutely true, however, the evidence is clear that D.D. was well read and up-to-date when it comes to medical knowledge of his day. (2, 3)

If D.D. could change his theory three times then why on earth would the chiropractic profession want to pick one of D.D.'s or his son's theories and etch them in stone? That is dogma that has no place in modern health care or modern chiropractic.

The Dalai Lama was once asked what Tibetan Buddhism would do if it was shown conclusively that there is no reincarnation, a central tenet of Tibetan Buddhism. His response, "Tibetan Buddhism will have to change."

Given that D.D. was "in to" the literature, (3) I am comfortable with saying I am a loyal chiropractor and will not bow to one of those four theories of chiropractic D.D. had. Today's chiropractor has the duty to follow in DD's footsteps and rethink chiropractic as the science dictates. I know that some sell to their patients that they do chiropractic as it was done in the past and actually get some people to think that practicing chiropractic as they think it was practiced 50 or 100 years ago is better than making appropriate changes when the scientific evidence suggests that there is a better way.

I'm sure expressed this way, that most people would say, "gee do I really want to go to a chiropractor whose methods are from the early 20th century?" I think not. I mean who would go to any professional and say, "please do not be up-to-date"?

The Foundation for Vertebral Subluxation wants to preserve a term, subluxation, that D.D. didn't use until after the trial of Shegatoro Morikubo for practicing medicine, surgery and osteopathy without a license in LaCrosse WI.(4) Subluxation and innate intelligence were first used by Smith et al in the first textbook on chiropractic Modernized Chiropractic .(5)

Many in chiropractic never learned the origin of the pseudo-religion or chiropractic philosophy. (6, 7, 8). It was nothing more than a legal tactic used in Morikubo's case. After Tom Morris, Morikubo's attorney got the medicine and surgery charges dropped, the tactic was to say that chiropractic and osteopathy had different philosophies and therefore Morikubo wasn't practicing osteopathy. In some ways it is unfortunate, because this was successful and then BJ etched into stone "chiropractic philosophy". (4)

The late Dr. Joe Keating wrote two articles about Morris that are available on-line
Tom Morris, Defender of Chiropractic Part I & Part II

I love the photo below. it is of BJ Palmer's rehab facility at the Palmer School of Chiropractic c1945. (BJ's signature is on each of the rugs)

What this shows is that even BJ Palmer wasn't so pure and straight as he "mixed" using rehab. The FVS wants to live today in a chiropractic past that did not actually exist. Their revised chiropractic history is a pseudo-religion that has no place in today's chiropractic beyond a class in the history of the profession. It is about as relevant to dealing with the needs of today's patient as sulfa drugs and mercury are for the medical profession.

The subluxation is dead, long live chiropractic.

  1. Keating JC, Jr., D.D. Palmer's Forgotten Theories of Chiropractic
  2. Gaucher-Peslherbe P-L. Chiropractic: Early Concepts in their historical setting. Lombard, IL: National College of Chiropractic; 1993.
  3. Gaucher-Peslherbe PL, Wiese G, Donahue J. Daniel David Palmer's medical library: the founder was "into the literature.". Chiropr Hist. 1995 Dec;15(2):63-9.
  4. Keating JC, Jr. B.J. of Davenport: The early years of chiropractic. Davenport, IW: Association for the History of Chiropractic; 1997.
  5. Smith OG, Langworthy SM, Paxson MC. Modernized chiropractic. Cedar Rapids, IA: Lawrence Press Co; 1906.
  6. Keating JC, Jr., Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF. Subluxation: dogma or science? Chiropr Osteopat. 2005 Aug 10;13:17.
  7. Mirtz TA. UNIVERSAL INTELLIGENCE: A Theological Entity in Conflict with Lutheran Theology. J Chiropr Humanit. 1999;9(1).
  8. Mirtz TA. The question of theology for chiropractic: A theological study of chiropractic'sChiropr Humanit. 2001;10(1).

Thursday, July 9, 2009

Bike Helmets

I can't remember how many times someone has sent me an email that is all about how we survived childhood without all the safety equipment that kids use today. The email goes on about concrete playgrounds, no seat belts no bike helmets etc. Yes it is true that we survived. But what about those who didn't from what now is a preventable cause of death.

Two days before I graduated from chiropractic college I turned my Honda Civic (they really tiny kind) into a Honda Accordion. I was distracted by a major collision, flashing lights everywhere, and plowed into a full size car at 50 MPH. If not for my seat belt I would surely have been ejected from the car and died. I was in a volunteer ambulance corps in high school and saw one of those where the car hit a telephone pole going much slower. Not pretty. I'm one of those who was "saved by the belt."

A few weeks ago, I was riding my bike to my office at the University of Bridgeport when a car made a right hand turn right in front of me. I hit a telephone pole with my head. But because of my children I barely was bruised. What do my kids have to do with my getting out of this relatively unharmed? I started wearing a bicycle helmet because they had to, plain and simple.

A recent study cited in the NYTimes found that states with helmet laws have far higher percentage of children who wear bike helmets. A big problem seems to be that for some the helmets are too expensive. Makes me wonder what's the problem with people who don't wear seat belts as all cars now have them. Cost can't be the reason.

I think the problem no matter what the safety device, is that people think, it won't happen to me. The odds are it won't but when it comes to bike helmets or seat belts the benefit far supersedes the costs in money or discomfort.


Surface deception - surface EMG

Although the article that stimulated this blog was published in February, I was only alerted to it by an automated Google news search, whose results that were emailed to me this week. The article is about the use of surface EMG to diagnose chiropractic subluxations. I won't go into the validity of the concept of the subluxation as I have co-authored a paper on that already, and the literature that supports or refutes our paper has not changed in any substantive way that I know of.

The article, sEMG: An overview, in my opinion, does little more than express, what I think, is a biased belief lacking any evidence that a subluxation can be demonstrated by sEMG. sEMG or surface EMG is a useful tool for certain purposes. One of those purposes doesn't happen to be diagnosis. It is really a research tool. Used to determine which muscle is active during certain movements. There are some sophisticated methods that are showing some promise in determining dysfunction that may be at the root of low back pain (1) or validating the diagnosis of low back pain. (2) but nothing I have seen suggesting that the sEMG can help find a subluxation. (3)

One fundamental problem with the use of sEMG to diagnose subluxations is that none of the methods used by my colleagues at this time involve what is called normalization. Normalization is where one converts the electricity measured during the sEMG to percent of maximum volitional movement or percent of some predetermined activity. The reason normalization is important is if one is just trying to compare the voltage from one patient to set of "normal" values inside the device one does not account for variables that change that voltage independent of muscle activity. For example, if one has an obese patient and thin one, the obese patient will have lower voltage readings on the EMG because fat is a great insulator without regard to the actual activity of the muscle. (4, 5) None of the sEMG devices that are marketed to chiropractors require normalization procedures before they produce their pretty computer graphics supposedly showing where the subluxation is.

Now most doctors of any profession lack the training that would provide them with the knowledge to evaluate the claims of the sEMG manufactures. However, if one reads the sEMG: An overview there are to simple clues to the lack of validity of these devices. The only references used are a twenty-two year old pilot study and a twenty year old book. Given the fact that approximately ten thousand papers are published weekly in the biomedical literature it is not that common that one needs to rely on such old references. Especially when professional groups both outside (6) and inside the chiropractic profession (7) have published since then noting the lack of validity of the use of these devices.(6, 7)

  1. Cholewicki J, Silfies SP, Shah RA, Greene HS, Reeves NP, Alvi K, et al. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 2005 Dec 1;30(23):2614-20.
  2. Geisser ME, Ranavaya M, Haig AJ, Roth RS, Zucker R, Ambroz C, et al. A meta-analytic review of surface electromyography among persons with low back pain and normal, healthy controls. J Pain. 2005 Nov;6(11):711-26.
  3. Owens EF, Jr. Chiropractic subluxation assessment: what the research tells us. J Can Chiropr Assn. 2002;46(2):215-20.
  4. Lehman GJ, McGill SM. The importance of normalization in the interpretation of surface electromyography: a proof of principle. J Manipulative Physiol Ther. 1999;22(7):444-6.
  5. Ng JK, Kippers V, Parnianpour M, Richardson CA. EMG activity normalization for trunk muscles in subjects with and without back pain. Med Sci Sports Exerc. 2002 Jul;34(7):1082-6.
  6. Pullman SL, Goodin DS, Marquinez AI, Tabbal S, Rubin M. Clinical utility of surface EMG: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 2000 Jul 25;55(2):171-7.
  7. Position Statement of the American College of Chiropractic Consultants on sEMG 2006