Perles of Wisdom

Anonymous Criticism - Defending Ernst

2010-12-19T17:23:00.000-05:00

Image via WikipediaAs with most bloggers who allow it I have received a variety of comments on my last blog, The self-importance of being Ernst. Generally it is my policy not to allow anonymous comments. Since I have the courage to identify myself in the blog I think anyone wanting to comment should do the same. Maybe that's my self-importance or it is my belief that one should have the courage of ones convictions.

Someone submitted a few comments in defense of Ernst to my blog and given that the email address is their web site and that their web site, which is just a tirade about various CAM methods, does not allow any commentary moderated or not from their readers I choose not to provide him/her with the links, i.e. advertising. However, I won't hide behind my ability to block a comment and will paste each of the comments and I'll reply. If my anonymous critic comes out from behind the curtain I might then publish as-is the words of this Wizard of Oz :)

Criticism 1

I noted in my previous blog posting that it was...unusual for Ernst to have a copy of Long's pre-submitted testimony, which was rejected by the CT Board of Chiropractic Examiners. My anonymous critic says:

If you read the ‘Methods’ section of Professor Ernst’s original paper he said that “several experts were also contacted for further data”. Perhaps that is how he managed to see Preston Long’s document.

Well that would be reasonable except that, Long doesn't fit any one's definition as an expert.Secondly one needs to keep in mind that Ernst was conducting a "systematic review". In a systematic review it is not uncommon to seek from other researcher, AKA experts their bibliographies of appropriate literature. Clearly Long isn't a researcher on the topic (or any other that I can tell). And one must remember that the data that Ernst was contacting others for was more papers in the scientific literature. See a larger quote from the Methods:

In addition, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data.

Criticism 2

Stephen Perle wrote: “What is the common feature of Ernst's citation of these deaths whose information or rather misinformation was obtained from a web site and the deaths reported by Long? Neither of these data sources were from the scientific literature. In his reply to our letter Ernst says "These cases were, however, merely added for completeness and not included in my total number of 26 cases reported in my review." Completeness? So adding people who didn't die after chiropractic spinal manipulation and weren't in the scientific literature adds completeness to a review of the scientific literature?”

Note that Professor Ernst said in his Introduction that:

Quote
“A responsible approach to serious therapeutic risks, however, requires an open discussion of the facts. In this review I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature.”

Note that he didn’t say he would *exclusively* look at the medical literature. Indeed, in the Methods section he was more specific, informing us that

Quote
“Electronic searches were conducted in the following electronic databases: Medline, Embase, AMED, Cochrane Library (September 2009)… *In addition*, our own departmental files and the bibliographies of the articles thus located were searched. Several experts were also contacted for further data. Case reports were included if they provided information on human patients who had died after receiving one or more treatments from a chiropractor.”

He goes on to say that many other fatalities seemed to have remained unpublished and gives examples of the testimony of Preston Long DC (whom it is likely that he contacted personally) which listed the family names of nine victims. Dr Long also stated that ‘many others are unknown hidden behind legal agreements of silence’. Professor Ernst then cites ‘names’ of further North American fatalities from the website www dot whatstheharm dot com

Well this isn't exactly true. The purpose says: "In this review, I aimed to provide the basis for such a discussion by summarizing all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature." Well the problem is my anonymous critic is grasping at straws. The purpose of looking in the departmental files or contacting experts are to find other papers in the medical literature that the search failed to find.

IF Ernst had a purpose that included all possible sources of information then that would have been in his methods. As I noted earlier if Ernst had put the information from Long in his discussion to coincide with the assertion that many cases are remain unpublished I would have only commented on the apparent collusion with critics of chiropractic not the propriety of including Long's "testimony".

My anonymous critic goes on to note the Ernst cites the names of other American fatalities found on the web site (cited above). Except that 5 of the 9 deaths that Ernst attributes to chiropractic spinal manipulation (in that paragraph of his paper but not in the total death count) did not die as a result of chiropractic spinal manipulation. So again if Ernst had only talked about these deaths to buttress his argument that the literature lacks a presentation of all deaths after chiropractic spinal manipulation I would not have criticized his lack of following his own purpose. But then again would have criticized his zeal to attribute all the deaths found on the web site to chiropractic spinal manipulation.

Criticism 3

Stephen Perle wrote: “Wenban has detailed the commonality of wrongly ascribing adverse events of manipulation to the care of doctor’s of chiropractic.”

As Professor Ernst says in his response to Whedon et al, his original review contests that with good references. He also says he can not reasonably be expected to know of the ‘personal correspondence’ that Wenban and Bennett cited and asserts that the small discrepancies in numbers (about which they argue) are almost irrelevant.

You know if we were talking about hundreds or thousands or even hundreds of thousands of deaths one or two discrepancies wouldn't matter would they? But and this is the amazing fact we are talking about a very small number - 26. So adding one that doesn't belong is big. I mean with a total of 26 in 115 years we are talking a 3.8% error. OK the number is a small point - it just goes to the sloppy nature of the review. Add a couple take away a couple and pretty soon you got nothing of substance in Ernst's "systematic review".
Criticism 4

Stephen Perle wrote: “Ernst says Cassidy's study has been repeatedly criticized for being flawed. The key word is repeatedly. This obviously repeatedly means more than once, which means that there must be more than one reference cited for that criticism. In fact, I think most would agree that repeatedly probably means many more than one. Well there is only one reference cited and what is that: Ernst E. Vascular accidents after chiropractic spinal manipulation: myth or reality? Perfusion 2010; 23: 73–4. No it can't be the only criticism in the scientific literature (not the blogosphere mind you - this is science we are talking about here) that Ernst can find is his own (now you get the idea about the title for the blog).”

Professor Ernst did not qualify where the study had been repeatedly criticised. Further, it you’re going to discount the blogosphere, then your blog post here should not, in any way, be taken seriously by the scientific community.

Well actually Ernst did qualify where the study had been repeatedly criticized. He provided ONE reference to the journal he is the editor-in-chief of. Since I know that my anonymous critic isn't a scientist (I know this from their former blog name) I'll forgive his/her ignorance about citation (and purpose above). However, given the fact that Ernst had no problem citing a web site as a source for the purported deaths, I am sure if his source for "repeated criticism" of Cassidy was the blogoshere or other web sites (even my anonymous critic's) there's no reason to suppose he wouldn't cite them. The fact of the matter remains that there have been no substantive criticism of Cassidy's methods in the scientific literature. There has been only one letter to the editor by Maigne. It is my opinion that Cassidy et al adequately responded to Maigne but clearly there isn't "repeated criticism" nor criticism substantive enough to deal a death blow to the validity or importance of Cassidy's findings.

I think one of the most important points one needs to keep in mind regarding cervical manipulation and stroke is that the only people going ape about this issue are critics of chiropractic. It just isn't an issue to epidemiologists nor any of the stroke associations. For example I was at a conference this year in Connecticut put on by the Connecticut Department of Public Health and the American Stroke Association on stroke in the young adult. Not one speaker mentioned cervical manipulation the whole day. The critical problem when it comes to stroke in the young adult is that despite its prevalence many health care providers don't recognize the condition because they think stroke is a condition of older people. Here are the stats I heard for strokes in CT for 2009, keep in mind the population of CT is about 3.5 million

Age Number of deaths

45-65 2047

25-44 354

15-24 34

4-14 10

<4 8

Clearly stroke is a horrible event to occur to anyone young or old. I know first hand from family members how devastating it is but right now the evidence just does not support a causal relation between cervical manipulation and stroke.

Finally I agree completely with my anonymous critic that no one in the scientific community should take my blog or any other blog seriously from a scientific stand point. That is why I didn't post anything on this blog until my letter to the editor was published. As I noted in the previous posting the way science progresses is not only the publishing of ones results but that there is an opportunity for critique in the same venue via letters to the editor. The more scientifically minded should read Ernst's paper, the letters to the editor and his response. In fact it is this reason that I have not posted my anonymous critics comments as is. Because I don't want to encourage people to see this person's opinion without the opportunity for rebuttal. If they posted their name and not their URL I would have not written a whole blog post and just let the comments go and commented on them as I have done herein.

Criticism 5

Stephen Perle wrote: “Now to his critique. I won't reproduce it here…”

Why not? For anyone wishing to read it, there’s a link to the full text of it in the chiropractic section of my website. It really is quite revealing.

Well the simple answer is I don't violate copyrights. The paper is copyrighted and neither my anonymous critic nor the other web site where I found the paper have anything about permission granted from the copyright holder to publish the paper on the web. The journal nor Ernst on his web site have a PDF available for free. I guess if one is really agitated about the chiropractic profession it is acceptable practice to violate copyrights. Zealotry trumps legality.

Also. I suggested that it is far better for people to listen to the cross-examination of Dr. Cassidy at the hearing that Long never came to. Again here is a link to the CT-N video of Cassidy's half day on the witness stand. Every point Ernst made and then some were tried by the two attorneys who cross-examined Cassidy. Hear the answers from the horses mouth.

Criticism 6

I think readers should be told that Dohos and Tragiannidis, of the Aristotle University of Thessaloniki’s Medical School in Greece, wrote to the International Journal of Clinical Practice in support of Ernst’s paper:

Quote:
“…we agree with Professor Ernst on the following points

• Vascular accidents after upper spinal manipulation can cause severe vertebral artery dissections;
• Numerous deaths have been associated with chiropractic neck manipulations;
• Many other cases are unknown behind legal agreements of silence
• Therefore the risks of chiropractic neck manipulations by far outweigh their benefits.”

Ref: Critique of review of deaths after chiropractic, 3. Dokos C, Tragiannidis A.
Int J Clin Pract. 2011 Jan;65(1):103-4.

The problem with Dohos and Tragiannidis is that they provide no substantive evidence for any of their bulleted opinions above.

Criticism 7

I also think readers should be made aware of the following in the US:

Quote
"The National Quality Forum lists 28 ‘never events’ healthcare mistakes that should never happen and need to be reported. Death or serious disability from spinal manipulation is listed as no.16. But chiropractors do not have to report this because they have a loophole. The National Quality Forum demands it of clinics and hospitals but no reporting is mandated for individual doctor's offices where 99% of spinal manipulation is done. Chiropractors generally do not practise in hospitals or clinics."
Ref: Britt Harwe, open letter to the Editor, Focus on Alternative and Complementary Therapies, Volume 15, Issue 1, pages 87-88, March 2010.

OK and the point? There are a lot of events that occur in private practices for which no reporting is mandated.

In conclusion I am waiting for the wizard of oz to step out from behind the curtain or not.

SMP

The self-importance of being Ernst

2010-12-16T23:10:00.009-05:00

Image via Wikipedia

Some may know Oscar Wilde's play The Importance of Being Earnest from which I've modeled the title of this blog entry. The play is a farce where obligations are shirked by assuming false identities. There is no discussion of false identities in this blog but there is a false presentation of objective science on the part of Dr. Edzard Ernst as Wilde writes in Act 1

I don’t play accurately – anyone can play accurately- but I play with wonderful expression.

In July the International Journal of Clinical Practice published a paper by Dr. Ernst titled: "Deaths after chiropractic: a review of published cases." When I read the paper I noticed some obvious errors. As opposed to some so-called science bloggers, rather than blog about it, I scienced. (I read once where a scientist said that one should use science as a verb, one sciences.)
I understand that Web 2.0 allows anyone to be a critic and possibly have great influence on public opinion (gee I am writing a blog about this). However, one of the fundamental differences between the scientific endeavor and other domains of thought is that knowledge progresses though the publishing of ones findings in a public forum after peer review and then subject to the possibility of letters to the editor which help clarify or critique or add information to that publication. When one submits a letter to the editor they are peer reviewed, as were the original manuscripts, and if one is using a bibliographic database such as PubMed the letters to the editor are hyperlinked to the record for the original manuscript so that people can find these important commentaries.

Here is a link to our letter to the editor on PubMed's web site. Copyright issues prevents me from providing the letter to my readers. We initially wrote a much longer letter but were informed after submission that the journal's maximum size is 500 words for a letter. I will provide the added detail in this blog.
The paper the letter is in regard to is: Ernst E. Deaths after chiropractic: a review of published cases. Int J Clin Pract. 2010 Jul;64(8):1162-5. In this paper Ernst's purpose was

In this review, I aimed to provide the basis for such a discussion by summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature.

In the results section of the paper he has a paragraph that is, to say the least, very interesting when one thinks of the purpose. Herein he describes "the testimony of the chiropractor Preston Long for a court in Connecticut recently listed the family names of nine victims." Ernst cites this with: "Presentation by Dr Preston Long DC to State of Connecticut. Connecticut State Board of Chiropractic Examiners. Hartford Connecticut.
25 October 2009. There was never a hearing before the State Board of Chiropractic Examiners on October 25, 2009. The hearing was in January of 2010 and because Long did not appear to under oath attest to his pre-submitted testimony it was, in accord with the procedural rules in CT not accepted and thus not part of the public record. One wonders how does Ernst get this document when it was not public. I have a copy as I was on the witness list and these pre-submitted testimony documents I was told were not to be made public until the board hearing.

Anyone wishing to see the hearing where Long's testimony is discussed should go to the CT-N web site here.
In that same paragraph Ernst cites nine deaths from chiropractic spinal manipulation that he found on a web site. When I read Ernst's paper one name stood out in my mind, Kimberly Lee Strohecker. I know a fair bit about Ms. Strohecker's very unfortunate death. I wrote about it in a 2004 ethics article titled J'Accuse...! (I Accuse). This article is about the death of Ms. Strohecker after a chiropractor got her to stop taking her anti-seizure medication. At least the federal court barred the chiropractor from ever practicing chiropractic again along with prison and a fine.

Yes her death was the result of a chiropractor's actions but they weren't due to chiropractic spinal manipulation. So I reviewed all the other people Ernst cited as dying from chiropractic spinal manipulation on the web site and discovered the Ms. Strohecker was one of 5 whose death might have been because of a chiropractors actions but weren't the result of chiropractic spinal manipulation.

What is the common feature of Ernst's citation of these deaths whose information or rather misinformation was obtained from a web site and the deaths reported by Long? Neither of these data sources were from the scientific literature. In his reply to our letter Ernst says "These cases were, however, merely added for completeness and not included in my total number of 26 cases reported in my review." Completeness? So adding people who didn't die after chiropractic spinal manipulation and weren't in the scientific literature adds completeness to a review of the scientific literature?

Now some reading this will say - gee that's picky. Well the point is ones method must fit ones stated purpose. Now if he had said in the discussion that there may be many more deaths after chiropractic spinal manipulation that aren't reported in the scientific literature and then cited these he would have at least stood on safer ground. Still 5/9 cases he said were after chiropractic spinal manipulation weren't. As we noted in our letter to the editor: "When obvious facts are wrong, the veracity of other facts, not as easily verified, must come into question." Science works in part because we have to have faith that what people write in their papers is in fact the truth. It is not truthful to say 9 people died when only 4 did. Thus can we trust the rest of what Ernst tells us?

Also Ernst cites an event that never occurred, Long's non-testimony before the CT Chiropractic Board. So again he cites something that is obviously not true. Thus can we trust the rest of what Ernst tells us? Some might say it is an honest error which if he was a newbie to scientific publishing I'd say give him a pass but I just did a PubMed search for Ernst E and found 1426 papers. I don't think he can claim to be a newbie.

Ernst cites a paper by Dziewas et al as presenting another case of a person who died after chiropractic spinal manipulation. However, one of the great features of modern electronic bibliographic searching technologies, such as PubMed, which Ernst used, is that letters to the editor also are found with the citation for every paper. When searching PubMed for Dziewas one finds a letter to the editor by Wenban. Wenban reported that the treatment was not provided by a chiropractor and thus cannot be chiropractic spinal manipulation. Wenban has detailed the commonality of wrongly ascribing adverse events of manipulation to the care of doctor’s of chiropractic.

A couple of the letters to the editor note that Ernst missed in his discussion the study by Cassidy et al that investigated the association between stroke and seeking care of a chiropractic physician or a medical physician and found no excess risk for seeking care with a chiropractic physician. I've blogged about this previously. In Ernst's reply he says about Cassidy's study "it has been repeatedly criticised for being seriously, perhaps even fatally, flawed e.g. (8). The ‘inconvenient truth’ might thus turn out to be a 'convenient untruth’." A long time ago I read an article that talked about somethings one can do to simply determine the validity of a paper one reads. One of those is references. Above Ernst says Cassidy's study has been repeatedly criticized for being flawed. The key word is repeatedly. This obviously repeatedly means more than once, which means that there must be more than one reference cited for that criticism. In fact, I think most would agree that repeatedly probably means many more than one. Well there is only one reference cited and what is that: Ernst E. Vascular accidents after chiropractic spinal manipulation: myth or reality? Perfusion 2010; 23: 73–4.

No it can't be the only criticism in the scientific literature (not the blogosphere mind you - this is science we are talking about here) that Ernst can find is his own (now you get the idea about the title for the blog). Anyway, you mean to tell me that none of the critics of this study had the testicular fortitude to write a letter to the editor? Cassidy's study was published in Spine and was part of the WHO's Bone and Joint Decade's Cervical Spine Task Force reports. Well OK Ernst didn't see fit to write his critique in the journal it was published in, as my colleagues and I did about Ernst's paper. You know those newbies to scientific publishing don't know that you should submit critiques to the journal it was written in. Well you remember those 1426 citations to Ernst in PubMed just 204 are letters to the editor. OK but let's look at his cited critique.

Ernst E. Vascular accidents after chiropractic spinal manipulation: myth or reality? Perfusion 2010; 23: 73–4.

Don't search too hard for this in PubMed. It's not there. The journal name is wrong. I know newbies sometimes get their citations wrong especially when they don't know the journal too well. Here is the proper citation.

Ernst E. Vascular accidents after chiropractic spinal manipulation: Myth or reality? Verlag Perfusion GmbH. 2010;23:73-4.

What do I know about Verlag Perfusion GmbH. If you look at their web site you'll see it is a German publication and the first editor listed is...Ernst. So I guess he's unfamiliar with the proper name for the journal.
Now to his critique. I won't reproduce it here but instead suggest listening to Cassidy answer these questions as they were posed to him before the CT Chiropractic Board you can see his testimony here.

Ernst in his paper on deaths after chiropractic spinal manipulation also says that there is no benefit to spinal manipulation. What's his reference for that. You guessed it, his own narrative review. Thus he ignores a growing body of systematic reviews showing benefit to spinal manipulation (1- 9)

There is one more item. In that list of 1425 papers in PubMed written by Ernst E there are 299 systematic reviews of these I count 37 which there is only one author. Of the 299 systematic reviews 17 are about the chiropractic profession. Has a real fixation on us doesn't he. Of the 37 systematic reviews with only one author 10 are about chiropractic. Or to put is another way of the 17 systematic reviews about the chiropractic profession 10 are single author systematic reviews. This is astounding. Why? Because standard practice in systematic reviews is to have at least two people. What is considered to be the preeminent international group conducting systematic reviews, The Cochrane Collaboration never does any reviews with one reviewer. Its just not done by almost anyone but...Ernst. In fact from the Cochrane Handbook:

It is essential that Cochrane reviews be undertaken by more than one person. This ensures that tasks such as selection of studies for eligibility and data extraction can be performed by at least two people independently, increasing the likelihood that errors are detected. If more than one team expresses an interest in undertaking a review on the same topic, it is likely that a CRG will encourage them to work together.

Well the self-importance of being Ernst is that he's the only expert whose opinion counts to Ernst.

SMP

Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):197-210. Pubmed record
Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Spinal manipulative therapy in the management of cervicogenic headache. Headache. 2005 Oct;45(9):1260-3. Pubmed record
Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):492-504. Pubmed record
Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med. 2007 Jun;13(5):491-512. Pubmed record
Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008 Jan-Feb;8(1):213-25. Pubmed record
Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15;33(4 Suppl):S123-52. Pubmed record
Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3. Pubmed record
Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther. 2010 Aug;15(4):315-33. Pubmed record
Miller J, Gross A, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manual therapy and exercise for neck pain: a systematic review. Man Ther. 2010 Aug;15(4):334-54. Pubmed record

The Vaccine Song

2010-10-20T10:46:00.001-04:00

Image by Getty Images via @daylife Today I saw this web site that has a country song about vaccines. The Vaccine Song

The song writer did a great job of hitting on all the issues in the vaccine debate. There are also good links to other resources on the web for more information on the issues. A few were new to me

What's the harm in vaccine denial?

The Truth About The Evils Of Vaccination

SMP

Science, sometimes - stroke and chiropractic

2010-04-17T07:00:00.016-04:00

Image via Wikipedia

The Connecticut Board of Chiropractic Examiners ruled on the issue of informed consent. There was a hearing on a declaratory ruling regarding informed consent and stroke. The board heard four days of testimony (which are available as videos at CT-N). Although the board's ruling hasn't yet hit the internet where I can find the exact text, it appears from newspaper reports that they ruled affirming that informed consent is the law in Connecticut but refused to require specific consent about a risk of stroke. Both the New Haven Register and the Hartford Courant have weighed in on this issue and it appears that science isn't the strong suit for either newspaper.

Both papers believe that there is a risk of stroke from cervical manipulation. Of course the two groups that advocated before the board for the ruling to require telling prospective chiropractic patients of the risk also believed there is a risk. To me what I have learned being part of this process is that science matters to many people only when it serves their interests.

Nature of science

Science is an epistemological theory. Epistemology is the study of how we acquire knowledge. Science, as we know it, is just one method to acquire knowledge through what's called the scientific method. Wikipedia's explanation of the scientific method is well done (at least today). Simply, the method is to observe some phenomenon, create a hypothesis (i.e. a prediction) about that phenomenon, then test that hypothesis by controlled observation, an experiment.

There are other epistemologies besides science. For example divine revelation where knowledge comes from a deity. Some have called my profession, chiropractic a cult because there are some in the profession whose epistemology is based upon the work of a guru, typically BJ Palmer. At one time most of medicine was based upon some guru's dogma. For example anatomy was controlled by the works of Galen (1st - 2nd century of the common era) who really didn't have a clue what was in the human body - he'd looked at monkeys as human dissection wasn't allowed in his time. It wasn't until a skeptic Andreas Vesalius (16th century) applied the empirical method - noting that the bodies he dissected didn't look the way Galen said that anatomy progressed beyond the dogma of Galen.

One common epistemology is the use of anecdotes. You know, "I once knew a guy who smoked a carton of cigarettes a day for 70 years and never got lung cancer. So cigarettes are safe." OK that's extreme but anecdotes have a tremendous hold upon our thinking and often it is very difficult to let science triumph when anecdote sits in contradiction of the science. Anecdotes which in health care publications are called case reports are very good at hypothesis generation, remember the scientific method is based upon an observation generating a hypothesis. Case reports can help generate a hypothesis but never can validate the hypothesis. I've heard it said often amongst skeptics of chiropractic that the pleural of anecdote is anecdotes not evidence. I'll come back to this quote again!

Autism and Vaccinations

I know it looks like I'm completely switching gears but there is a logic to my digression. As I have thought a lot about stroke and manipulation and autism and vaccinations I've come to see that they are analogous situations. Think about this, a family has what appears to be a healthy normal baby. They are in this blissful state of early parenthood enthralled with the baby who is developing a similar love for them. Then suddenly the developing relationship on the babies side changes and the child becomes distant. The parents seek advice and find that their now more withdrawn child appears to have autistic spectrum disorder. To the parent this can be a devastating event. They want desperately to find a cure and if there isn't a cure (which there doesn't seem to be) they want to blame someone, something. This is only natural. The parents feel as if someone, something has taken their child away from them. Then they hear about a supposed link between autism and vaccinations. Now they have people to blame. They can blame the vaccine manufactures. They can blame the government for trying to tell us that vaccines are safe. They can blame their doctors for giving their baby this poison which caused the problem. To hear the anti-vaccination folks go on about autism and vaccines is to hear the voice of anger and vindictiveness. They are not malicious people just untrained in the ways of science and prone to letting their emotions have greater sway over how they look at the evidence.

What about the evidence? Those parents when confronted with the scientific evidence that does not support their belief that autism is caused by the vaccine, reject the evidence. What is the basis for the rejection, valid critique of the science? No, usually it is what comedian Stephen Colbert called truthiness. Truthiness, which was the Merriam-Webster word of the year in 2006, is defined as: "Truth that comes from the gut, not books," and "The quality of preferring concepts or facts one wishes to be true, rather than concepts or facts known to be true."

Then a whole support industry develops around this belief. There are organizations whose purpose is to advocate on behalf of the parents and spread the word that autism is definitively caused by vaccines. This theory is advanced in such a way that reading the web one might believe it was the only one.

I was a participant in a webcast on vaccines for the California Department of Public Health titled "Wading through the Confusion". As one of my colleagues on the webcast, David G. Amaral, PhD, an autism researcher from the UC Davis M.I.N.D. Institute lamented is that there is inadequate research money available to find the cause of autism because the theory advocated by these groups has so dominated the discussion.

[Any one wishing to know more about this battle should read Paul Offit's book Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure. The NYTimes article on Offit is enlightening about the lack of civility of public discourse on this issue.]

Back to Stroke

Now think about ischemic strokes. Isn't this what happens after a stroke in a younger person. I mean we sort of think of stroke as a disorder that affects the elderly and it is. The CDC lists death from stroke as the third most common cause of death behind heart attacks and cancer. The rate of stroke increases dramatically as one ages. Stroke is a life changing event that affects not only the person who may be disabled, but the entire family and other caregivers as well. Utility analyses show that a major stroke is viewed by more than half of those at risk as being worse than death. (1)

So a younger person, say in their 40s - 50s has a ischemic stroke. That person and their family are going have the same desire as the family who finds their child has developed autism, find someone to blame. Well instead of a radicalized group of parents spreading the word that vaccines are the cause for autism there is a radicalized group of patients spreading the words that it must be a visit to a chiropractor. This theory that chiropractic cervical manipulation is the cause of strokes in the young has become so common that many MDs speak as if this is an established fact. They don't really know what the research says about stroke but couple their distrust of chiropractic (2) which I think is a result of the AMA's illegal boycott(3) and it's easy to see how they would assume the connection between chiropractic care and stroke is valid. Plus why search the literature to find this out, most people they know will tell them it is true. It seems scientific evidence doesn't always matter.(4)

What is the epidemiology of these strokes? They are rare representing 2% of all ischemic strokes but 10 to 25 percent of strokes in the young and middle aged.(5) These facts are not well known so when someone in who is young or middle aged presents to a hospital with a stroke everyone wants to know why. Given the bias and bad information then the question comes, "did you see a chiropractor within the past month?" This only serves to expand the perceived value of this belief. It is not uncommon to hear someone say that the risk is proven. Proof is a word I tell my students that they can never use when referring to biomedical research. There is either evidence that supports or refutes a particular hypothesis. IF they want PROOF then their career choice should become mathematics not health care.

Or that there is 80 years of science backing this up. Well time to go back to that earlier quote: "the pleural of anecdote is anecdotes not evidence." There isn't an 80 year history of science with respect to the association between cervical manipulation and stroke, there is an 80 year history of anecdotes that appears in the scientific literature. The real science behind this issue has a much shorter history. We get a survey of neurologists in 1995 (6) with a very poor response rate and which suffers from referral bias. (7) Plus a survey doesn't establish cause and effect. There are many studies of cases that have tried to discover the incidence. For example this paper by Haldeman et al which estimated that one chiropractor in 48 would during the course of their practice career would be made aware of an arterial dissection following cervical manipulation. But none of these papers actually evaluated the risk.

There are only three studies that have evaluated the risk of stroke after manipulation. And all three agree there is an association. (9- 11) The first two found a risk (9, 10) and the third (11) finding the same association provided evidence that explains the first two. Cassidy et al (11) used the same data sources as Rothwell et al (9) but Cassidy et al study investigated one thing neither Smith (9) nor Rothwell (10) did and that is they determined the background rate of these strokes. The issue is if the rate of strokes after chiropractic care was greater than the background rate (those that were occurring spontaneously not caused by the manipulation) then we would know what the added risk was due to manipulation. The finding, the rate of strokes in patients under 45 seeking care from their primary care physician was identical to the rate for those who had seen a chiropractor. Thus seeking chiropractic care produced no extra risk for stroke over and above the background rate. It appears that patients about to have a stroke from a dissection of a vertebral artery (the kind blamed on chiropractic for 80 years) seem to go to a doctor (a medical doctor or a chiropractic doctor) and the only reason the association between chiropractic and stroke appeared to be strong and not for PCPs is that no one asks the question in the emergency room, "did you see your MD within the past month?"

Some have complained that Cassidy et al was a "statistical study" (see this opinion piece or listen to Dr. Murray Katz's testimony before the Connecticut Board of Chiropractic Examiners) That's almost comical as a critique if not that it might ring true to people who don't understand biomedical research. Those same critics never said that Rothwell (9) and Lee (10) were "statistical studies" which they are.

In the publication BottomLine Health there is an article about stroke risk. The author Dr. Steven Messe essentially dismisses cervical manipulation as a risk factor based upon Cassidy et al's work.(12)

The nature of science is that what was known one day may change the next. This isn't often comfortable to the average person but it is the way it is.As the late Prof. Natalia Romalis-Reytblatt (she was a math professor at UB and UB’s 2006-07 Professor of the Year) wrote:

Mathematical results are either false or true (that is, proven or false) and nothing in between. Mathematics is one of the oldest fields of study and, probably, the only field whose findings are not reversed over time, only accumulated.

Math doesn't reverse it's findings but biomedical science does. A few years ago I wrote about the risk of stroke from cervical manipulation. But then the evidence changed. So in the end this is an argument about looking at the science or ignoring the science and using emotion or choosing to use old science only. To hear the science you can listen to Dr. David Cassidy testify before the board. You can decide.

SMP

Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline. Stroke. 2006 Jun;37(6):1583-633. (this paper is available for free here)
Busse JW, Jacobs C, Ngo T, Rodine R, Torrance D, Jim J, et al. Attitudes toward chiropractic: a survey of North American orthopedic surgeons. Spine (Phila Pa 1976). 2009 Dec 1;34(25):2818-25. (Pubmed link)
Getzendanner S. Permanent injunction order against AMA. Jama. 1988;259(1):81-2. (Pubmed link)
Gabbay J, le May A. Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care. Bmj. 2004 Oct 30;329(7473):1013.(this paper is available for free here)
Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. (Pubmed link)
Lee KP, Carlini WG, McCormick GF, Albers GW. Neurologic complications following chiropractic manipulation: a survey of California neurologists. Neurology. 1995;45(6):1213-5. (Pubmed link)
Haldeman S, Carey P, Townsend M, Papadopoulos C. Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias. Spine J. 2002 Sep-Oct;2(5):334-42. (Pubmed link)
Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ. 2001 Oct 2;165(7):905-6. (this paper is available for free here)
Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001;32(5):1054-60. (this paper is available for free here)
Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003 May 13;60(9):1424-8. (Pubmed link)
Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83. (Pubmed link)
Messe SR. Stroke Risk. BottomLine Health. 2010;24(3):1-2.

Decompression - Yeah right

2010-03-28T22:55:00.003-04:00

Image by planetc1 via Flickr

Marketplace, a Canadian Broadcasting Corp (CBC) investigative TV show did a piece on decompression for low back pain. This news item might get a lot of people angry. I figure those who get mad will mostly be those who own and market the "decompression" machines. Some of my chiropractic colleagues might get mad because they might believe that the chiropractic profession is put in a bad light but really I don't think so. There was no inference that the problem with decompression machines is a chiropractic problem, the news piece just looked at one chiropractor's offices. In fact they note that the College of Chiropractors of Ontario (the regulatory board for chiropractors in ONT) after being notified by Marketplace, will be investigating the chiropractor in the news piece regarding his advertisements.

So what are these non-surgical decompression machines? Well they are just low back traction devices that cost a lot of money, thus require lots of patients to make the expenditure worth the money for the doctor. Big bills means big advertising. It is not uncommon for one to see very large advertisements in local newspapers. These ads often have lots of claims of great success rates. There are also claims that these are NASA technology. Well those claims don't hold water as Marketplace found. In fact the Oregon Attorney General's office has ruled that neither of these claims are valid and can't be used in Oregon. I guess it's too bad if you live elsewhere. I live in Connecticut and regularly see these ads in my local paper.

The real problem here is that people suffering with back pain are vulnerable to believing the advertisements because they are desperate to get relief. The ads make it sound so good. Go to the office, get an exam (may be just a wallet exam) and then get relief from this device with NASA technology and an 86% success rate. Seems too good to be true, and of course it is.

Are there people with low back pain for whom traction is helpful? The answer is yes but it shouldn't take thousands of dollars and months of care. Research (1, 2) is starting to identify those people for whom traction is the best option but a definitive answer hasn't bee found yet.

So what is a poor suffering person to do? Well one needs to find the doctor who isn't quick ordering any treatment or isn't really a one trick pony. That means one that doesn't do traction on everyone. Or doesn't do spinal manipulation on every patient. Or doesn't schedule surgery - first thing. Or doesn't say exercise is a must for everyone. Really treatment needs to be individualized to the patient. One method for doing that is to use what my colleague Dr. Donald Murphy of the Rhode Island Spine Center has published as the diagnosis-based clinical decision rule.(3, 4) There is more research that needs to be conducted on this method but I think it's the best model for how to manage the patient with spinal pain and determine the appropriate treatment.

SMP

1.    Fritz JM, Lindsay W, Matheson JW, Brennan GP, Hunter SJ, Moffit SD, et al. Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? Results of a randomized clinical trial and subgrouping analysis. Spine. 2007 Dec 15;32(26):E793-800.
2.    Raney NH, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Deyle GD, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009 Mar;18(3):382-91.
3.    Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord. 2007;8:75.
4.    Murphy DR, Hurwitz EL, Nelson CF. A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature. Chiropr Osteopat. 2008;16:7.

Zero Tolerance - Sex With Patients

2010-02-05T20:55:00.001-05:00

Image by Getty Images via Daylife

The College of Chiropractors of Ontario (the equivocate of a state board of chiropractic examiners) suspended the license of a chiropractor for 5 years for professional misconduct. The doctor in question, treated his girl friend and then marked her bills paid. She submitted them to insurance and would give him the funds. After they broke up he tried to collect the balance of her account and then referred her account to a collection agency. She didn't complain about his having had a sexual relationship with her, she complained about his billing practices. Nevertheless there is a zero tolerance policy for having sex with patients and the College
The college's decision was based upon one salient fact, the doctor was having sex with a patient. The nature of their relationship was immaterial.
The issue which I've stressed in my classes on ethics and risk management as well as my ethics column that any relationship founded upon an imbalance of power is not consensual. In the doctor-patient relationship the doctor has the professional knowledge and knowledge is power. Thus there is a professional boundary between the patient and the doctor that can never go beyond that relationship.
SMP
For more details see the article in the Globe and Mail: Giving care to his girlfriend puts chiropractor in hot water or on CTV Waterloo chiropractor loses his license

Foot Detox Pads

2010-02-03T08:22:00.000-05:00

Image by welovepandas via Flickr

Laura Johannes writes in the WSJ online about the silliness called foot detox pads. Congratulations for getting to the bottom of this pile of crap. The sale of these pads and the use of ion detox foot baths are proof positive that science hasn't really affected the thinking of enough Americans to prevent snake oil salesman from making a living in our modern age.

The great irony of today's internet, driven by content sensitive advertising is that the "sponsored links" just below her article are for three companies that sell the items she has just attempted to debunk. Gotta love adsense or is it nonsense.

SMP

Autism's False Profit - Disciplined

2010-02-02T23:18:00.001-05:00

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Andrew Wakefield is the medical doctor whose discredited research started the whole scare over MMR causing autism has been disciplined by the General Medical Council (GMC) in the UK. The GMC (the regulatory agency that oversees the medical profession in the UK) ruled that Wakefield had showed a “callous disregard” for the suffering of children. They also ruled that his research was deceptive.

Wakefield and colleagues published a paper in the prestigious and venerable British medical journal, The Lancet which detailed 8 children who supposedly became autistic after getting the MMR vaccine. The children had gastrointestinal symptoms which lead to the theory that the vaccine changed the permiablity of the GI track and allowed substances into the blood and eventually to the brain resulting in autism. The paper said that the children were consecutively seen when this was not true. Most of the authors retracted the paper 6 years after it was published and today the journal completely retracted the 1998 paper that created all the controversy. What allowed the journal to retract the paper was the GMC's decision that the paper was deceptive.

I guess one could say too little too late. On the other hand I view this as the self correcting nature of science. Clearly there has been significant harm because of this paper and the hysteria it has provoked. Those who believe that vaccines are the cause of autism, of course, will not let any amount of scientific evidence change their minds. As it is said “You cannot reason people out of a position they have not reasoned themselves into.”

SMP

NY Times article about this

Destroying the best health care system

2009-11-05T11:31:00.041-05:00

Image by craynol via Flickr

The great myth that some opposed to health care reform propagate is that we have the best health care system in the world and any reform effort will destroy it. Nicholas Kristof destroys this myth in an Op-Ed piece in the NYTimes.

The argument goes our health care is the best so reform will only destroy it. Except that we are 31st in life expectancy, 37th in infant mortality, 34th in maternal mortality. I could go on but check out Kristof's column yourself.

The biggest problem I see is the reliance of the masses upon cable news or radio to learn what the truth is. I do not suggest that anyone take Kristof's take as the reality find out the facts for yourself.

For example I had a friend send me an email about how the health care reform bill was going to make seniors get end of life counciling. You know Ms. Palin's idiot rant. I didn't listen to Palin or any of the so called experts in the email - I went to the Library of Congress' web site and searched though the bill in question for myself.

Kristof provides the reference to where is data come from: The Robert Wood Johnson funded study by the Urban Instiitute How Does the Quality of U.S. Health Care Compare Internationally? Thus, one need not read my or Kristof's spin.

As my dad told me as a kid don't believe what people tell you find out for yourself.

SMP

Health Care - Controlling Costs? Control Behavior

2009-10-21T21:33:00.001-04:00

When we hear about health care reform and the importance of controlling costs the fundamental problem is that we can't really control costs by legislation. To control costs we need to do one thing, change behavior. The billion dollar question, ok it's probably a 700 billion dollar question is whose behavior? The answer everyone's, doctors and patients.
NPR and PRI's The American Life recently had a series of pieces on the costs of health care. They have, I believe, laid out the complicated but fundamental problem insimple way.

Doctor's perform too many procedures that people don't really need.
Patient's demand too many procedures that they don't really need (and doctor's cave-in and order or do those procedures
Advertisements are fueling the demand for costly drugs.

There are other issues too.

The high cost of drugs. My own insurance policy changed. In the past we paid 5, 10 or 15 dollars co-pay on a prescription. Now the co-pays can be higher. Oh boy can they be higher. I've had dandruff and the shampoos that one could buy at the supermarket weren't working anymore. So the dermatologist wrote me a perscription for a shampoo that worked like a dream. I've used the stuff for 3 years. It was great, depending on the season using this 1-2 times per week (only approximately tablespoon full) and I was fine.
Well with the change in insurance this shampoo wasn't covered. The cost...over $300 for a small bottle! By small I'm talking a 4oz bottle! The pharmacist said that he wouldn't pay that much for shampoo unless it "got him a supermodel." I've got a different prescription shampoo now. It's only $125. Cheap? Ok, cheaper! Still the problem was I was completely insulated from the extreme cost of the shampoo. I would suspect that the vast majority of people using that shampoo were likewise insulated from the cost and thus there was no market pressure to cut the cost. Think about how much the cost of a band name drug drops once the patent protection runs out and their are generics. Of course the brand name never gets as inexpensive but it still is cheaper.

American's LOVE brand names. I remember when I got my first Polo brand shirt. The little guy on the polo pony was on embroidered on the shirt tail. Too see the logo one would have to really know where it was to see it. Now of course it's critical that everyone actually see the logo to know you own a Polo. I think this is way Tylenol is still one of the best selling drugs, even though one can buy a generic for much less. People buy expensive brand names when the generic is cheaper.

Watch and wait - a treatment approach

2009-09-24T11:35:00.002-04:00

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The September 22nd issue of the Wall Street Journal has an interesting column by Melinda Beck, "Getting Well: It's About Time." To make it simple this about about how so much waste is involved in our health care system because we are impatient. For many conditions one would do best to just wait. In a previous blog I present an anecdote about Dr. Paul Glasziou using the best treatment for his 2 year old's otitis media, "watch and wait". Ms. Beck cites a few different doctors who note the value of such a non-treatment approach.
There are a bunch of great quotes in this piece:

"Most people's bodies and immune systems are wonderful in terms of handling things—if people can be patient," Ted Epperly
"I have a mantra: You can do more for yourself than I can do for you," - Raymond Scalettar

The estimate is 1/3 of the US expenditures on health care would be saved if we did less, when appropriate. Ms. Beck presents a list of when one shouldn't wait such as signs of stroke, heart attack, majory injury etc.
The bottom line is better health care decisions on both patients' and doctors' parts would save us a ton.

"The art of medicine consists in amusing the patient while nature cures the disease."
Voltaire (1692-1778)

SMP

Baseball and health care - evidence based care

2009-09-24T11:20:00.000-04:00

Image by The Library of Congress via Flickr

As I hear more debate (or is it partisan rancor - I mean despite obvious lies not one Democrat disrespected the office of the President and yelled to President Bush liar) regarding health care reform I am reminded of a remarkable Op-Ed piece from the NY Times (of course) by the strangest of bed fellows: Billy Beane, Newt Gingrich And John Kerry. For those who do not know Beane is the VP and General Manager of the Oakland A's, I might be wrong but I figure everyone else knows former Congressman Gingrich and Senator Kerry.

Just brings Garrett Morris as Chico Escuela on SNL- "Baseball be berra good to me"

Why would baseball be a benchmark for health care? Because baseball is a game of statistics and coaching decisions and in particular staffing decisions are made by using those statistics. The use of a newer way of looking at baseball statistics is what Beane is known for. It is called sabermetrics. And the point of this op-ed is better health care is possible if we use the data, i.e. evidence based health care.

SMP

Malpractice 3

2009-09-18T10:27:00.005-04:00

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In today's CT Post, Robert A. Levine, MD writes an Op-Ed on health care reform and malpractice. I have to say that when I saw the headline I thought this was going to be another kill the lawyers piece that I see so often. Or maybe another Republican-like plan to restrict the amount of jury awards to people actually harmed by negligent care.
Instead, Dr. Levine presents a cogent argument about what is wrong with our current system and suggested objectives that any reform measure should include.
I would post a link to his article but unfortunately the publishers of the CT Post have never read "What Would Google Do?" (WWGD is a great book by Jeff Jarvis which would argue that the CT Post should put the whole content of the newspaper on-line for free - remember what has Google every charged you? ZERO).
Dr. Levine's five objectives in any system intended to address medical negligence and malpractice are:

Decreasing the incidence of negligence and improving quality of care
Properly and rationally compensating individuals who have been significantly injured as a result of negligence
Removing incompetent physicians from patient care
Punishing physicians guilty of negligence
Having a process both patients and physicians believe is equitable.

As I've noted in previous blogs about malpractice a large problem isn't frivolous suits but negligent care. Dr. Levine notes that many who are seriously injured never receive any compensation because they don't file suit. Currently too many bad doctors, regardless of the specific profession continue to practice or shall I say malpractice.
Hopefully, any plan to come out of Congress doesn't just limit the amount paid out in malpractice cases for all that will do is ensure that some patients who really need compensation don't get it.
SMP

Swine Poop - Swine Flu & Chiropractic II

2009-09-09T10:34:00.005-04:00

Image by Gonzalo Fernández via Flickr

To quote President Reagan "there you go again". Once again a high profile chiropractor is there suggesting in a press release that chiropractic spinal manipulation is part of a reasonable flu prevention strategy. See my previous blog entry on Swine Flu & Chiropractic.

I know I could sit back and wait for the blogosphere of chiropractic critics to appropriately lampoon this press release. But then they would imply the entire chiropractic profession believes this but I won't be painted with that same paint brush.

I'll put it in the simplest language possible. This idea that "nerve interference" somehow leads one to be vulnerable to infection is swine poop. And the idea that one needs to see a chiropractor to make sure that there is no "nerve interference" so that one's children's immune systems will function at their best is swine poop, too.

As Max Planck wrote in 1936:

An important scientific innovation rarely makes its way rapidly winning over and converting its opponents; it rarely happens that Saul becomes Paul. What does happen is that its opponents gradually die out and that the growing generation is familiarized with the idea from the beginning.

Unfortunately, when it comes to chiropractic the opponents of rational thought and the scientific method within chiropractic seem to reproduce er proselytize before they die out. Thus, this pseudo-religious thinking persists within chiropractic medicine. Exposing this pseudo-religious thinking does not appear to force it underground. (1, 2) It seems that the Internet has allowed this form of lunacy to flourish as much as any other form of C.R.A.P. (convoluted reasoning anti-intellectual pomposity)

The most insidious part of this press release is that the writer has a legitimate degree in public health, an MPH. This might give the laity the belief that this is a legitimate idea. Likewise, one of those cited in the press release has an impressive sounding title as president of an organization with an impressive name. None of this provides any evidence that the press release actually presents valid information about the importance of the subluxation.

The fact that the CDC is cited also gives the illusion that this press release has some scientific merit. It only shows that the writer knows how to package this swine poop so it looks good. Or as was used so often in the last US presidential election, he's put lipstick on a pig. The central premise, go to a chiropractor so he/she can remove the subluxation which causes nerve interference which leads to a poorly functioning immune system is still swine poop.

Obviously the writer of the press release is intelligent. But as I noted in an earlier blog ideological immunity is not the domain of the unintelligent.

Now of course the author of the press release might posit that it is I who have the ideological immunity and just can't see the profound value to one's immune function by removing the ubiquitous nerve interfering subluxation. He might be right. Sometimes people with deviant thoughts are right: think the long road to that Drs. Marshall and Warren traveled before the role of H pylori in duodenal and gastric ulcers and stomach cancer was acknowledged.

However, as Carl Sagan wrote in Broca's Brain:

I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence.

Clearly the idea that subluxations cause nerve interference which then reduces the effectiveness of the immune system is an extraordinary claim and it requires extraordinary evidence. I think as with any rational scientist I am willing to be shown to be wrong in my assessment and change my thinking. The growth of scientific knowledge is made by shattering the previous truths. BUT one won't shatter the current state of scientific evidence exclusively with the pronouncements or press releases of a self-professed expert. Show me the beef er the research that subluxations cause nerve interference and that it reduces the effectiveness of the immune system. Since we wrote our paper on the subluxation (3) I've not seen any evidence yet that our assessment was wrong.

Please prove us wrong by providing extraordinary level of scientific evidence (heck how about any valid scientific evidence). I'll tell you if those who believe this swine poop think that the first author on our paper, the late Dr. Joe Keating would be rolling in his grave if the evidence was presented, I'm here to assure you that I know he'd be cheering. Because Joe and the rest of the authors are basically saying put up or shut up. Please put up or shut up!

SMP

1. Mirtz TA. UNIVERSAL INTELLIGENCE: A Theological Entity in Conflict with Lutheran Theology. J Chiropr Humanit. 1999;9(1). free full text here
2. Mirtz TA. The question of theology for chiropractic: A theological study of chiropractic's prime tenets. J Chiropr Humanit. 2001;10(1). free full text here
3. Keating JC, Jr., Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF. Subluxation: dogma or science? Chiropr Osteopat. 2005 Aug 10;13:17. free full text here

The Making of the American Health Care System

2009-09-03T07:00:00.006-04:00

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A colleague gave this to me to post anonymously.

October 26, 1943: Healthcare’s Pearl Harbor

Unlike that actual Pearl Harbor attack on Dec. 7, 1941, the health care Pearl Harbor which occurred two years later did not make headlines, was not addressed by President Roosevelt in a joint session of Congress and did not result in massive death and destruction. Indeed, there were probably only a small handful of people who were even aware that some happened on October 26 that affected health care.

But like Pearl Harbor, the events of October 26, 1943, were cataclysmic. They changed, fundamentally, irrevocably and for the worse, the trajectory of the health care system for the next 66 years (and counting). To understand the events of that day we have to back up a few years to beginning of WW II. Within months of our entry into WW II the size or our armed forces swelled from a few hundred thousand to many millions, eventually peaking at 16 million men and women in uniform. Almost all of these 16 million were taken from the existing workforce. This resulted in very severe manpower shortages in industry. As well, the Defense Department (known then as the War Department) consumed huge quantities of natural resources (rubber, iron, coal, gas, etc.). These manpower and resource shortages necessitated the implementation of wage and price controls for the duration of the war.

Private sector industries were desperate for workers but were prohibited from offering high wages to attract them. They were permitted to offer some benefits, health insurance among them, without violating the wage and price rules. It’s worth recalling the state of health insurance (and health care itself) at this time in history. Health insurance in 1941 was an anomaly. Both the Kaiser system and the Blue Cross systems were developed in the 1930s, but these touched very few lives. Overall, more than 95% of the population was uninsured. In 1941 health care expenditures accounted for less than 2.5% of GDP as compared to 17.6% of GDP today. But this data point doesn’t even begin to describe the minimal state of health care at the time. Today we spend $8,300 per capita on health care. In 1941 we spent, in 2009 dollars, $325 per capita on health care. (I spent twice that much last week in one dental appointment.) As compared to the health care industrial complex of today, the health care system was a cottage industry in 1941.

In any case, the wartime health insurance benefit did become a popular and effective means of attracting workers. And then came October 26, 1943. On that date the question was answered: Are employer-based health insurance benefits taxable as income? Until that day there was no answer to this question. Mostly companies offering health insurance did not report this as income, but some did. All these companies wanted a clarification from the IRS.

It is not recorded whether there was any political debate on this question. Were there advocates (perhaps the insurance companies) of tax-free health insurance? We don’t know. Were there opponents of such (perhaps budget-conscious Congressmen)? We have no idea. Were there any discussions of the possible implications of this ruling on our health care system? It’s very unlikely. Certainly given the state of our health care system at that time no one would have thought to utter the phrase, “We have to get our health care spending under control.” This would have been nonsensical. If there was any active consideration of this policy it surely would have been something like, “Health insurance? More people having health insurance is a good thing. Let’s leave it alone.” Or something like that. So, on October 26, 1943, a person, panel, of committee who to this day is unknown and un-named, ruled that employer-provided health insurance is not taxable income. And the rest is history. (In 1954 an act of Congress finally ratified and made permanent this IRS ruling.) Before detailing the mostly deleterious effects of this event, lets’ quickly recount the trajectory of the health care system over the next few generations.

As millions of servicemen and women were demobilized and returned to the civilian workforce the concept of the health insurance benefit had reached a critical mass. In the heavily unionized industries the addition of a health insurance benefit became one the most sought-after benefits of collective bargaining. And in the professional and managerial classes the offering of a health insurance benefit continued to be useful recruiting tool. In 1941 there were fewer than 5 million people in the US who had some sort of medical/hospital insurance. By 1950 that had grown to over 100 million, most of this based on employer-provided insurance. (Interestingly, individually purchased health insurance also increased rapidly during this period and peaked in about 1970 and thereafter steadily shrank as a mode of health insurance purchase.)
Along with this revolution in health care funding came a revolution in health care itself. In 1941 Sulfa drugs were just being introduced. Penicillin and other antibiotics were still several years away from practical use. Insulin to treat diabetes had been in regular use for several at this point and you did have a good chance of surviving appendicitis surgery and basic obstetrical care was probably doing some good as well. And if you had a serious cut or laceration could stitch you up and hopefully avoid infection. But that was about it. Even with the best health insurance plan in existence it would still have been very difficult to find much to spend health care dollars on. And then everything changed. Without belaboring the point there was an explosion of health care technology: New antibiotics, new steroids, new psychoactive drugs, heart surgery, transplant surgery, chemotherapy, radiation therapy (not entirely new), CT, MRI, PET scans, Gamma knives, stents, implants, new hips, news knees, new lenses, cochlear implants…the list goes on and on. (It is another story whether or not all of these advances are in fact advances, but that’s a different story.)

All of this increased health care purchasing power and expansion of medical technology obviously dramatically increased the demand for services and it quickly became clear that our health care infrastructure was inadequate to service this demand. Multiple pieces of legislation were enacted to correct this. Most notably the Hill-Burton act of 1946 provided funding for the construction of new hospital facilities. The goal was to achieve a density of 4.5 hospital beds per 1,000 in all locales of the country. Many other pieces of legislation during this post-war period subsidized and expanded the health care infra-structure including a dramatic expansion of the health care workforce.
Thus there were three forces that drove health care from being a cottage industry to being a Mega-industry:

Increased health care purchasing power
Increased health care technology
Expanded health care infra-structure

Collectively these three forces have produced a 25-fold increase in per-capita health care spending since WW II. The principle engine that drives this explosion of health care spending is employer-based health insurance.

Which brings us finally to the issue of why the October 26, 1943 tax ruling has been so damaging to our health care system:

1. It has tied health insurance to employment. One thing that everyone hates about our health care system is that for most people the only practical way to secure health insurance is through one’s employer. The tax advantage offered by this mode of insurance makes other options impractical or unavailable. And so our health insurance is only as secure as our job and we end up making career decisions based on the effect if will have on our health insurance status. All of this is a stupid, inefficient and arbitrary way to organize both our health care system and our workforce.

2. It has subsidized the purchase of health insurance. In 1943 the idea of subsidizing the purchase of health insurance probably seemed like a pretty good idea. It could hardly be said at the time that we were over-insured. But over the decades those of us who do have employer-based health insurance are typically over-insured. When it is possible to buy $1 dollars worth of insurance for $0.75 (which is the effect of the tax subsidy) we will rationally choose to buy more health insurance that would otherwise be the case. When health insurance was still in its formative years (1945-1965) most insured people had what as called “major medical” insurance, that is, catastrophic insurance. But over time this has become the exception rather than the rule and the insurance subsidy has resulting increasingly lavish and comprehensive insurance policies. The idea of insuring against large and unforeseen health care expenditures has been replaced by the idea of insuring against routine and predictable health care costs.

3. It has separated the purchaser (patient) and seller (doctor, hospital) from the cost implications of health care. In 1965 a threshold was passed: more than half of all health care expenditures were paid by third parties. Prior to the health insurance revolution most health care was paid for as you would pay for anything else—out of pocket. And since 1965 the percentage paid by third parties has continued to rise and has now leveled-off at about 80%. No other sector of our economy is characterized by such a triad (buyer, seller, payer). In this triad the buyer is essentially indifferent to cost and provides no brake on utilization or price. The seller is of course is incentivized to increase price utilization and finds little resistance from the buyer. And the payer tries vainly, and to no one’s satisfaction, to apply some brakes to the system. The buyer’s indifference to cost is further manifested by their indifference to the cost of health insurance itself. The perception on the part of the employee is that their company’s health benefit is “free” or most free depending upon their contribution. In fact the cost of employer provided health care is 100% paid for by employees in the form of lower wages. But this fact is not visible and in fact believed by most even when they are apprised of this fact. (It must be noted that economists have extensively studied this question and there is no disagreement on this issue.) Being indifferent to the cost of insurance employees are only interested in expanding the benefit as much as possible in the mistaken belief that it is free to them and this of course further exacerbates the problem of over-insurance.

4. It has artificially increased the demand for health care services. In 2009 over 100 million advanced imaging studies (CT/MRI) will be performed in the US. One in four Americans will have an imaging study of some sort, some of them, multiple studies. No, not all of them are unnecessary. I imagine there are several million people who will benefit from these studies. But most of these 75 million imagees (is that a word?) will not benefit and the fact that they will not is entirely understood and predictable. This excess (and the excesses of every other procedure, device, drug that is a part of our health care system) is only possible through the artificially pumped-pumped up demand created by subsidized employer sponsored health insurance.

5. It has crowed out other forms of health insurance. If one is employed and if one’s employer offers a health insurance benefit, it would be economically irrational to forgo this benefit and attempt to buy an individual policy with after-tax dollars. There is no possibility of getting as much for your money as you would with your employer’s plan. And so no one acts in this manner and thus the individual and small group insurance market is atrophied and inefficient. To be sure, without the tax incentive, employer-based health insurance would still be a viable option. We do, after all, sometimes get life insurance and disability insurance through our employers without the inducement of tax subsidies. And employer-based health insurance is an effective way to pool risk. But an efficient and effective insurance market needs more than just one viable and practical option.

6. It has ultimately resulted in a positive feedback loop of cost escalation. And so, for the past 67 years we have been caught in an ever accelerating positive feedback loop of health care cost increases. As medical technology and infrastructure expand the need to fund this expansion drives up the cost and the need for health insurance. An anxious public is frightened to death at the prospect of paying for the scan, the surgery, the drugs and this public makes clear to the employers that their health insurance benefit must keep pace with these costs. The employers oblige as best they can and continue to fund premiums which tend to increase at about twice the rate of underlying inflation. And the next round of technology and price increases is thus funded and the process continues. Thus, we spend 17.6% of our incomes on health care, soon to break the 20% barrier.

It would be a vast oversimplification and simply wrong to suggest that all of our health care woes are caused by tax-subsidized, employer-based health insurance. But it is not wrong or an oversimplification to suggest that this is the single biggest factor driving the inefficiencies of our system. And it is, frankly, an easy problem to fix. But it appears that we won’t get this fix. Instead we are being to treated 1000+ page health legislation which will not become law in any case. Let me offer a 39-word health care reform bill that just might do the trick:

The Commissioner of the IRS shall revise the tax code such that from 2010 to 2015 the portion of employer-based health insurance benefits that is treated as taxable income shall increase in a linear fashion from 0% to 100%.

Preventing Deaths From Treatable and Preventable conditions

2009-09-02T23:42:00.006-04:00

Image by seiuhealthcare775nw via Flickr

The health care debate rages on and most of the discourse seems to be full of opinions that are bereft of data. A recent NYTimes editorial notes that an Urban Institute study shows that American health care does somethings right and others wrong. The Times editorial highlights the fact that American health care seems to fail at preventing deaths from treatable and preventable diseases.
While the most jingoistic Americans are blind to the quality problems in our health care system, the recognition that the American health care system could do better has been known for a long time. One of the most through studies about quality of American health care was published by the Institute of Medicine over a decade ago.
Crossing the Quality Chasm: The IOM Health Care Quality Initiative

The IOM Definition of Quality is one I think everyone should keep in mind:

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

With so many people complaining that they don't want the government to decide on health care decisions, I wonder why we have assumed that insurance companies, for whom less payments to health care providers means more profit, are some how better than the government without profit motive would do. Whether it is the government or a for profit company making decisions on what health care interventions are appropriate and should be paid for, it would be nice if this definition of quality were foremost in everyone's mind.
SMP

Stupid Until Proven Intelligent - MD & DC Relations

2009-08-27T10:42:00.005-04:00

Image via Wikipedia

Around 1986-7 I was the medical director for a track meet at West Point. At that time I was in charge of all medical care for all of the Metropolitan Athletics Congresses events. I must have worked at 40-50 track and cross country events a year.

Whoever was a top US 100m high hurdler fell and hurt her leg. The pain was on the lateral side of her lower leg. A tuning fork test suggested an unusual fracture one of the fibula. The tuning fork test is where one puts a 128Hz turning fork on a bone with a suspected fracture (not right over the site of injury) and the vibration is supposed to irritate the fracture side and cause pain.

I drove this woman to the base hospital and spoke to the admission clerk, reporting a suspected fibular fracture. The attending was standing nearby and overheard me. He said, “don’t you mean tibia?” I replied, “no, fibula.” He asked why I thought fibula. As I said this is not a common fracture.

I said location of pain and a positive tuning fork test. That of course provoked questions about the tuning fork. I said that it was a standard on-field screening test in sport medicine.

MD: “Sports medicine? That’s a specialty?”

Me: “I’m certified” {I was a CCSP (Certified Chiropractic Sports Physician - except due to NYS bizzar rules I was supposed to call myself a Certified Chiropractic Sports Practioner}

MD: “I didn’t know there were fellowships in that?”

Me: “I did post grad training”

He then asked if I could show him how to do it on a woman just brought in by ambulance. She crashed on the base ski run. He had to get a nurse to unlock the cabinet with the tuning forks. They had the box set with every frequency. I took out the 128Hz and showed him how to use it. Later after my athlete’s radiographs came back negative we talked some more. He asked what hospital I work at and then I said, “I don’t, I’m a chiropractor.”

Lindsay Rowe, DC, MD taught me this "technique" to deal with medical prejudice towards chiropractors. He said that to many MDs you are stupid until proven intelligent if they know you are a chiropractor. So prove you are intelligent and then let them know you are a chiropractor. I’ve used it often to great effect.

The example Lindsay gave me was that before he went back to get his medical degree, he used to travel the US. Wherever he was he'd call the local medical school and try to speak to the head of radiology department. On the phone he would introduced himself as a radiologist from NZ with interesting cases. Lindsey is a board certified chiropractic radiologist. {BTW two studies have shown that chiropractic radiologists (DACBR) are as good as anyone else in reading skeletal films.(1, 2)} If he got to meet with the radiologist they'd play what I call, "stump the radiologist."

Then when they were done trying to stump each other he’d reveal he was “only” a DC. Lots of surprised looks. He was invited to give grand rounds a few times and audience was only told what his training was at the end. Most couldn’t believe it because of course we’re all dumb as door-nails.

I've used this technique for many years. Fortunately, I don't run into such overt prejudice as often as I once did. My favorite example was the MD at a cocktail party who upon hearing I was a chiropractor dropped my hand, mid-handshake, spun on his heels and walked away without a single word.

Because of my work with the ING New York City Marathon and the New York Road Runners I often come in contact with MDs and haven't had that kind of thing happen. I guess that means my profession is moving more into the mainstream of health care, but we have work yet to do to be completely in mainstream health-care.

SMP

1. Taylor JA, Clopton P, Bosch E, Miller KA, Marcelis S. Interpretation of abnormal lumbosacral spine radiographs: A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic. Spine. 1995;20(10):1147-54.
2. de Zoete A, Assendelft WJ, Algra PR, Oberman WR, Vanderschueren GM, Bezemer PD. Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists. Spine. 2002 Sep 1;27(17):1926-33; discussion 33.

Uncientific America - A Pluto Moment

2009-08-25T15:23:00.015-04:00

Image by the mad LOLscientist via Flickr

The LA Times (what not the NY Times) has an article about Chris Mooney & Sheril Kirshenbaum's new book, Unscientific America. The article, by Lori Kozlowski, Bringing science back into America's sphere laments the pitiful state of America's understanding of science.

The "demotion" of Pluto from a planet is used as a metaphor for what people know about science. It seems that the Pew Research Center did a study about what the public understands when it comes to science. They found that 60% knew that Pluto had been reclassified. On the other hand 54% thought that antibiotics kill viruses and 46% knew that electrons are smaller than atoms.
Given how little the public knows about science Kozlowski writes:

It is exceedingly rare that science does anything that reaches almost everybody anymore. So, when you get your moment to put it all before everybody, you don't want it to be a Pluto moment.

If science is going to be a candle in the darkness (as the late Carl Sagan subtitled his great book: The Demon-Haunted World) then it needs to go viral. It has to grab the imagination of the public. In the preface to The Demon-Haunted World, Sagan relates how he had a limo driver ask why science guys, like Sagan, didn't work on finding the secret to unlimited power that supposedly powered the mythical island of Atlantis. This event was one reason why such a serious scientist, as Sagan, would write popular books. He wanted to make science interesting to the masses.

Kozlowski then talks about how so many people erroneously believe that vaccinations cause autism. These people are often well to do and educated. In a book that is similar to Sagan's Michael Shermer, in
"Why people believe weird things: Pseudoscience, Superstition, and Other Confusions of Our Time" writes:

In day-to-day life, as in science, we all resist fundamental paradigm change. Social scientist Jay Stuart Snelson calls this resistance an ideological immune system: 'educated, intelligent, and successful adults rarely change their most fundamental presuppositions.' ... That is, the higher the IQ, the greater the potential for ideological immunity.

Maybe Mooney & Kirshenbaum have figured out how to break though ideological immunity and to make the excitement of the discoveries of science go viral. I'll have to add their book to my list to read.

SMP

You can only do the best you can do

2009-08-19T22:05:00.005-04:00

Image by hbp_pix via Flickr

This weekend I helped supervise triage at the NYC Half Marathon. It was to say the least a HOT day. The vast majority of people I saw were with a little support, and salt able to leave my area under the own power. A few were not able to and went to the hospital. It's rather nerve racking to stand by as those who do the next level of care take over. It gets worse when they get carted off to the hospital and one is left without knowing what is going on. You run the event though your mind, was there something I could have done better, could I have gotten to the athlete sooner, etc. And then you hopefully come to the conclusion, as I did, that lacking a finish line in an ER I did the best and I know those I handed the athlete off to, likewise did their best. In the end the athletes recovered and you can only do the best you can do.

Diet

2009-08-12T10:52:00.002-04:00

Image by Getty Images via Daylife

If you have not seen it Time has a great series on eating, diet etc. titles The Way We Eat.

SMP

Biking & Bones

2009-08-11T12:30:00.003-04:00

Recent studies, discussed in a NYTimes blog have found that cycling is a risk factor for low bone density or osteopenia. This finding is actually not unexpected. Bone mass is in part determined by the amount of load / force applied to the bone. Thus, as noted in the blog runners, weight lifters and triathletes have higher bone mass than cyclists (keep in mind that triathletes do a significant amount of running too).
These findings stress the importance of weight bearing exercise and especially for females. Swimming and cycling while both great exercises do not put adequate stress on bone to stimulate bone deposition thus predisposing the swimmer and cyclist to osteopenia and osteoporosis.

SMP

Vaccines: "Wading through the Confusion"

2009-08-11T07:39:00.003-04:00

I was invited last year to participate in a webcast about vaccinations. This was conducted by the California Department of Public Health. They invited me because they had searched the web and found an article that I did with Randy Ferrance, DC, MD on vaccinations for Dynamic Chiropractic in February of 2005: What's Good for the Goose Is ... Ethics and Vaccinations

Here is a link to the webcast on vaccinations. It is a 60 minute program. We taped about hours of material which were edited down to this.

I think the production team headed by Lars Ullberg (he's the on camera moderator) did a great editing job.

Other members of the panel were:

Ken Reibel is a journalist with a autistic son who blogs at Autism News Beat An evidence-based resource for journalists
Frankie Milley (and her husband Bob) lost their only child Ryan Wayne Milley, to Meningococcemia/Meningococcal Meningitis on June 22, 1998 - she started meningitis advocacy group for meningitis a vaccine-preventable disease called Meningitis Angels
Mark Sawyer, MD from the San Diego County Immunization Branch, and a pediatrics professor at the University of California, San Diego,
Rahul K. Parikh, MD is a physician and writer in the San Francisco Bay Area.
S. Michael Marcy, MD, UCLA Center for Vaccine Research
David G. Amaral, PhD is an autism researcher from the UC Davis MIND Institute
Kristine Sheedy, Ph.D., Associate Director for Communication Science, National Center for Immunization and Respiratory Diseases, CDC Atlanta, GA
Jamie Betters, a parent of small children

A few of the panelists have written papers on the topic of immunization which I think are very important. Citations below:

Gust D, Brown C, Sheedy K, Hibbs B, Weaver D, Nowak G. Immunization attitudes and beliefs among parents: beyond a dichotomous perspective. Am J Health Behav. 2005 Jan-Feb;29(1):81-92. pubmed record
Amaral DG, Schumann CM, Nordahl CW. Neuroanatomy of autism. Trends Neurosci. 2008 Mar;31(3):137-45. pubmed record
Thompson WW, Price C, Goodson B, Shay DK, Benson P, Hinrichsen VL, et al. Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. N Engl J Med. 2007 Sep 27;357(13):1281-92. Marcy SM is one of the et al pubmed record
Parikh RK. Fighting for the reputation of vaccines: lessons from American politics. Pediatrics. 2008 Mar;121(3):621-2. pubmed record

There are a lot of web sites that present theories or vitriol regarding vaccinations. The link to the video also links to other valuable web sites on vaccinations.

SMP

What does it take to put an ugly fact through the heart of a beautiful hypothesis?

2009-08-06T08:29:00.004-04:00

NPR yesterday did a piece on treating fractured vertebra and so did the NYTimes This is hot news because two papers appeared in the New England Journal of Medicine that compared vertebroplasty to placebo and found them comparable.

The great problem is that the treatment is perceived by both doctors and patients as effective. This treatment provides opportunity for discussion about a huge problem for health care reform. When common knowledge suggests a treatment is effective but the data show, in a compelling way, that the treatment (which has risks and financial costs) is no better than placebo should insurance pay for the treatment?

The fear of some is that because a treatment does not appear to be clinically effective "big brother" will say, "we won't pay." I understand the fear that some all powerful insurance company will get to decide what is and is not effective. But is this bad, per se? I do not think so. Both doctors and patients have for years mistakenly believed that various treatments that aren't effective actually are. I've blogged on this before, see Treatments That Don't Work.

I recently read a great paper whose title I love: What does it take to put an ugly fact through the heart of a beautiful hypothesis? (1) The title is from a quote by Thomas Huxley who lamented "The great tragedy of Science - the slaying of a beautiful hypothesis by an ugly fact." The point in this article is that our modern history of health care is full of beautiful hypotheses, that some treatment is effective, slayed by a ugly fact, research showing the treatment to be ineffective. The problem is that although the hypothesis, that the treatment is effective is dead, the belief in the effectiveness of the treatment isn't dead. Both doctors and patients alike have resurrected these treatments that ugly facts have slayed like the zombies in the classic Night of the Living Dead.

Another quote from Haynes (1) paper from Max Planck, renowned physicist

‘‘A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it.’’

However, it seems that while opponents of the new scientific truth die they unfortunately are capable of infecting a new generation that because of truthiness will accept these slain hypotheses.

Truthiness, is defined by Merriam-Webster as:

Truth that comes from the gut, not books
The quality of preferring concepts or facts one wishes to be true, rather than concepts or facts known to be true.

For more on truthiness and the danger it poses for patients see my article in Dynamic Chiropractic, The Dangers of Truthiness

As Prof. Dov Cooperman of the University of Maryland wrote in a letter to the editor of Newsweek: "...our society is more than happy to accept spin and cant because we have come to believe that all expertise is bias, that all knowledge is opinion, that every judgment is relative. I see this daily in my university classroom. Many of even my best students seem to have lost the ability to think critically about the world. They do not believe in the transformative power of knowledge because they do not believe in knowledge itself"

Unfortunately I see it everyday in my classroom and hear it from many of my professional colleagues too.

My final quote from Haynes (1): Samuel Johnson, the 18th century poet and critic

‘‘The chains of habit are too weak to be felt until they are too strong to be broken.’’

The habits that are so problematic are a lack of critical thinking skills and reliance upon the "wisdom" of others (i.e. dogma), unsystematic and uncontrolled observation, and just truthiness.

For more information on critical thinking I recommend the Foundation for Critical Thinking.

SMP

1. Haynes RB, Haynes GA. What does it take to put an ugly fact through the heart of a beautiful hypothesis? Evid Based Med. 2009 Jun;14(3):68-9. Pubmed link

Talent is Long Patience

2009-07-31T09:33:00.010-04:00

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!

SMP

A couple of other articles on the need to practice

Secrets of Greatness
The Expert Mind

Preventing vs. Postponing - will health care reform save money

2009-07-30T09:17:00.012-04:00

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.

SMP

Cultural Authority and the Chiropractic Profession

2009-07-25T20:40:00.006-04:00

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

2009-07-25T18:05:00.001-04:00

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.

SMP

Two views of chiropractic

2009-07-23T20:36:00.006-04:00

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.

SMP

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

2009-07-23T18:22:00.004-04:00

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.

SMP

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.

Rationing Health Care

2009-07-19T20:33:00.007-04:00

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.

SMP

Malpractice

2009-07-17T10:56:00.003-04:00

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.

SMP

Chiropractic In the News Downunder

2009-07-13T08:33:00.005-04:00

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.

SMP

Foundation for Anachronistic Chiropractic Pseudo-Religion

2009-07-10T20:16:00.010-04:00

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.

SMP

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

Bike Helmets

2009-07-09T13:20:00.003-04:00

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.

SMP

Surface deception - surface EMG

2009-07-09T09:01:00.004-04:00

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)

SMP

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.
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.
Owens EF, Jr. Chiropractic subluxation assessment: what the research tells us. J Can Chiropr Assn. 2002;46(2):215-20.
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.
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.
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.
Position Statement of the American College of Chiropractic Consultants on sEMG 2006

The Weakening of Professionalism and the High Cost of Health Care 2

2009-06-18T15:27:00.007-04:00

NPR's Fresh Air did an interview yesterday with Dr. Gawande. This is adds to the discussion from his article that I talked about in my earlier blog on this. He talks about some interesting comments made to him by doctors from McAllan. It's worth listening to in addition to reading the article in New Yorker.

SMP

Sick to debt

2009-06-09T07:46:00.005-04:00

Instead of being sick to death many Americans are sick to debt. They are in so much debt that they have declared bankruptcy. To me this is obscene that people, in some cases, though no fault of their own have become sick to debt or so ill that their physical illness leads to the ultimate financial illness - bankruptcy. A study in the American Journal of Medicine found that in 2007 62.1% of Americans who filed for bankruptcy did so because of medical bills, over $5000.

Most of these people were in middle class jobs, owned their homes, were well educated and actually had health insurance. These aren't the kind of people one thinks of as getting in financial trouble due to medical bills. I mean most had health insurance. There clearly is something wrong with the system when someone with health insurance has to declare bankruptcy. I think most would have figured that the people in this financial bind were the so-called working poor. You know 3-4 part time jobs with no health insurance. Either way this is obscene. I know that some will say that it's not my problem but it is. The money that can't be paid back is absorbed by the overall economy. Thus each of us pays for this.

There ought to be a better way!

SMP

David U. Himmelstein, Deborah Thorne, Elizabeth Warren, Steffie Woolhandler, Medical Bankruptcy in the United States, 2007: Results of a National Study, The American Journal of Medicine, In Press,

The Weakening of Professionalism and the High Cost of Health Care

2009-06-03T11:16:00.005-04:00

I think that the Obama administration is correct that health care costs need to be reduced if we are going to improve our economy. We don't have the best health care in the world but we certainly have the most expensive.

This week's New Yorker has a great article about what drives up the cost of health care. The article by Atul Gawande, MD. Dr. Gawande compares the cost of health care in McAllen TX to nearby El Paso. The two areas have basically the same demographics and health statistics - so it's not the people. Yes El Paso's Medicare expenses are about half of McAllen's. McAllen has amongst the highest health care costs in the US. On the other hand Rochester, MN, home of the Mayo Clinic has one of the lowest.

I suggest reading the article but my take on this is very simple. The doctors at Mayo live up to the moral principle that created the social contract whereby society granted autonomy to professionals (classically health care, clergy and attorneys). Society created the social contract because it lacked the knowledge needed to properly understand and regulate the professions. The contract states that professions get the autonomy to practice as long as they subjugate the needs of the profession and professional to the needs of the patient, parishioner or client. The Latin phrase credat emptor replaces caveate emptor. The later, we all know means let the buyer beware. The former is let the buyer have faith. That is have faith that the recommendations that the professional makes are in the "buyer's" best interest not in the professional's.

Dr. Gawande's research shows that in McAllen and I suggest spreading around the US is an anti-professional ethic in health care to, as he writes, not leave money on the table. This means that one has made sure to bill for everything one can possibly bill for. I am a capitalist but I think this is a problem of values.

I've written in my ethics column in Dynamic Chiropractic about values. Below the lists of values from the Rokeach Value Survey. There are two types: Instrumental Values and Terminal Values. The former are those values that explain how we live our lives and the later are what we want out of life.

Instrumental Values

Ambitious
(Hard-working, aspiring)
Broadminded (Open-minded)
Capable (Competent, effective)
Cheerful (Lighthearted, joyful)
Clean (Neat, tidy)
Courageous (Standing up for your beliefs)
Forgiving (Willing to pardon others)
Helpful (Working for the welfare of others)
Honest (Sincere, truthful)
Imaginative (Daring, creative)
Independent (Self-reliant, self sufficient)
Intellectual (Intelligent, reflective)
Logical (Consistent, rational)
Loving (Affectionate, tender)
Obedient (Dutiful, respectful)
Polite (Courteous, well-mannered)
Responsible (Dependable, reliable)
Self - controlled (Restrained, self discipline)

Terminal Values

A world at Peace (free of war and conflict)
Family Security (taking care of loved ones)
Freedom (independence, free choice)
Equality (brotherhood, equal opportunity for all)
Self-respect (self esteem)
Happiness (contentedness)
Wisdom (a mature understanding of life
National security (protection from attack)
Salvation (saved, eternal life)
True friendship (close companionship)
A sense of accomplishment (a lasting contribution)
Inner Harmony (freedom from inner conflict)
A comfortable life (a prosperous life)
Mature love (sexual and spiritual intimacy)
A world of beauty (beauty of nature and the arts)
Pleasure (an enjoyable leisurely life)
Social recognition (respect, admiration)
An exciting life (a stimulating active life)

I think that the cost of health care is due to the elevation of "A comfortable life (a prosperous life)" over "A sense of accomplishment (a lasting contribution)". This might be the rebound or backlash of the “60s”. I started practicing in NYC when Jerry Rubin (Chicago 7) hippie became a yuppie. There is a nice discussion of how he debated his co-conspirator Abbie Hoffman in the Wikipedia article on him under the subheading post activism. When I was in NYC in the early 80s I used to go to Jerry Rubin’s networking parties at the Palladium where business people went to meet other business people. I found it a waste of time. Nevertheless, life, it seems, had changed to profit mattered more than accomplishment.

Or to put it another way professionalism matters because until the prevailing ethic amongst all health care providers stops being the health of their personal wallet and it properly is the patient's health and value they receive from our care no effort will reduce cost with increases in health and wellness.

SMP

A NICE approach to treating low back pain

2009-05-29T10:06:00.012-04:00

NICE which is the UK's National Institute for Clinical Excellence has just released guidelines for treating low back pain (LBP).

The first recommendation is to promote self-management. This means to suggest to patients with LBP to exercise and try to continuing doing ones normal activity, as possible. The next one is pain medication - first acetaminophen. The final recommendation is exercise or manual therapy (i.e. spinal manipulation) or acupuncture.

Another interesting feature is what the guidelines proscribe. All of the following are treatments/diagnostic tests that are NOT allowed (because they either don't work or aren't needed):
Medical/Surgical treatments

SSRIs for pain management
Facet injections
Radiofrequency facet joint denervation
IDET (Intradiscal Electrothermal Annuloplasty)
PIRFT (Percutaneous Intradiscal Radiofrequency Thermocoagulation)

Physical therapy

Laser therapy (AKA Cold Laser)
Interferential electrical stimulation
Therapeutic ultrasound
TENS (another kind of electical stimulation)
Lumbar supports or belts - back braces
Traction

Diagnostic tests

Plain film x-ray under any circumstances
MRI to be offered only to rule out red flags or for surgical referral

I think of an MRI for a a back pain patient, a road map for a surgeon. Keep that in mind if you are pushing your doctor to get one.
Red Flags are signs of:

Spinal cancer
Cauda equina syndrome
Infection
Ankylosing spondylitis or another inflammatory disorder
Fracture

Of course as I noted in previous blogs, it is likely that your health care provider will ignore these recommendations and do what they have always done, even if the scientific evidence is that it is not effective.

See:

These new guidelines are is not particularly new but nice to see.

SMP

Ultracrepidarian Doctors and Back Pain

2009-05-15T07:57:00.009-04:00

An ultracrepidarian is a person who professes expertise the they do not posses. This is an epithet not often used but I am fond of and have used in presentations and my ethics column. Some might say that fondness is because it should be applied to me. Nevertheless, I like it because I find so many experts who pontificate on that which they know so little. Think of my earlier blog entry about Katz.

There is a classic paper that sort of tested the prevalence of this disorder amongst very smart college students. The title says it all, "Unskilled and unaware of it: How difficulties in recognizing one's own incompetence lead to inflated self-assessments". (The link goes to free full text)

A new study, published in today's Spine by Buchbinder et al could be called ultracrepidarian doctors and back pain. The paper, "Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain" details a study that surveyed general practitioners about their interest and knowledge regarding how to treat back pain. The results are counter-intuitive because those with the greatest interest in treating back pain had the poorest knowledge of the current best evidence of how to treat it. Thus, they were ultracrepidarians.

It was almost comical but the doctors with a special interest in back pain thought that guidelines are very helpful in determining how to treat patients with back pain, yet they choose treatments, such as bed rest, that are clearly bad for patients. Bed rest in particular has been known to be harmful for a long time.

This paper is very similar to one published quite a while ago also showing that doctors choose treatments that are ineffective and avoid ones that are effective such as spinal manipulation.

Buchbinder and colleagues previously published studies that showed that public education reduces disability from workers compensation type claims. Sometimes the public is teachable and their doctors aren't. I wish I could give patients hope that the doctor they go to really is up-to-date but clearly if the doctor says they are does not mean that they actually are.

SMP

Resistance to using the best treatment

2009-05-10T10:57:00.005-04:00

The NYTimes reports on the battle against the use of the best evidence in health care. Once again it is reported that one of the biggest problems in getting good health care is the resistance of health care providers to changing the voodoo that they do to treatment that actually works.

This article talks about the Agency for Health Care Policy and Research's guidelines on treating lower back pain. (1) Spine surgeons were so upset that it excluded their favorite treatment - surgery - that they tried to kill the agency. As the Times article reports the reason that surgery was not recommended: research didn't show it was effective but it did show that spinal manipulation was effective.

But as Max Planck said: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it."

The problem is that people have a hard time changing. Most hate change. Personally I thrive on it. Most don't like finding out they were wrong. I used to be like that. I think the change was when I read the first study that suggested that spinal manipulation might be effective for treating some people's symptoms who have spinal stenosis (2)

This paper came out 2 years after I had told a patient who came in with CT showing the stenosis (he'd been symptomatic for ~10 years) that I couldn't help him and he should have the surgery he had scheduled. The study isn't what I'd call compelling evidence of clinical effectiveness of spinal manipulation but IF it had been published two years earlier I could have told this man he might have a 36% chance of getting better after two weeks of care. Given the fact he'd lived with the pain for 10 years he might have been willing to try two weeks of care instead of "going under the knife". For a while I beat myself up over this and then I realized, you can't know what isn't known. That liberated me to be comfortable with saying that was wrong. As W.V. Quine and J. S. Ullian wrote in The Web of Belief (Random House, New York, 2nd edition, 1978, p. 133) my favorite quote:

The desire to be right and the desire to have been right are two desires, and the sooner we separate them the better off we are. The desire to be right is the thirst for truth. On all accounts, both practical and theoretical, there is nothing but good to be said for it. The desire to have been right, on the other hand, is the pride that goeth before a fall. It stands in the way of our seeing we were wrong, and thus blocks the progress of our knowledge.

The Times article suggests that most doctors are more interested in having been right, rather than being right.

SMP

Bigos S, Bowyer R, Braen R, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994.
Kirkaldy-Willis WH, Cassidy JD. Spinal manipulation in the treatment of low-back pain. Can Fam Phys. 1985;31:535-40.

Ye Of Little Faith - In Chiropractic That Is

2009-05-03T07:18:00.012-04:00

My last blog entry Swine Flu & Chiropractic is stirring up a hornets nest. Of course you wouldn't know that by looking at my blog because no one has posted any comments, so far. I have received quite a few emails. All of the emails sent to me directly by the person commenting have been complimentary.

I haven't yet received any anonymous hate mail, such as when my colleague Randy Ferrance, DC, MD and I co-authored one of my ethics columns for Dynamic Chiropractic on vaccinations, entitled What's Good for the Goose Is ... Ethics and Vaccinations. (BTW I think we would write this differently now due to a change in the evidence on stroke and chiropractic.)

That column resulted in such an outpouring of venom directed at Dr. Ferrance and me that I wrote a column about Argumentum Ad Hominem (ad hom for short) - which is to attack the person not their argument. For some reason, I do not completely understand, many people in my profession will resort to ad hom rather than find the flaws in an argument they think is wrong. To quote from my Dynamic Chiropractic article: "This is the most feeble reply one can make and generally reflects poorly upon the person who does it. Those who are not biased see this as having no probative value in the argument, and it signals that the person using that reply has no valid counterpoint and is not acting professionally."

Lack of Faith

Some think that my last blog entry shows I lack "faith" in chiropractic. Well clearly I do lack faith in chiropractic, just as I lack faith in medicine, physics, mathematics...

I think that faith is not an appropriate word to describe ones association with ones profession. No one would ask a mathematician, "do you have faith in math?" However, one might ask a member of the clergy do you have faith in your religion. This is because one is obligated to have faith in a religion. There is no other method for one to accept the tenets of a religion, as there is no method to determine the validity or lack of validity of those tenets. Faith is a belief that does not rest on logical proof or material evidence.

I do have faith in the epistemology (a subset of philosophy) inherent in science (i.e., skepticism, empiricism and determinism). Science is an epistemological theory about how one acquires knowledge and cannot be validated using the scientific method. Using science to validate science is a tautology. Thus one must have faith that science is a good method to discover how things function. So far it has worked out pretty well. You are reading this because of thousands of scientific discoveries that ultimately lead to blogging (not sure this is science's best day).

Chiropractic is a health care science and thus starting with my faith in science, I am forced not to have faith in chiropractic but to conclude, based on the available science that chiropractic is or is not a useful method for the care and prevention of human illnesses or maladies.

Given the above, I have found evidence that I find to be compelling to make me conclude that chiropractic is an extremely valuable method for the care and prevention of human illnesses or maladies. I will not blindly have faith in chiropractic or anything else, I will question it constantly, that I believe is my job as an academic.

Narrow view of chiropractic

One chiropractors suggested that my blog entry shows that I have a narrow view of chiropractic and that I implied we should stick to headaches, low back and neck pain. I wrote:

There is a growing body of good scientific evidence that spinal manipulation can be an effective treatment method for neck pain, headaches and low back pain.

Tell me where does it say that we should "stick to headaches, low back and neck pain"? It doesn't. It says that there is a growing body of good scientific evidence on three conditions. That's all. I didn't mention any others.

If one wants to see a good review of what evidence there is take a look at the Council on Chiropractic Guidelines and Practice Parameters (CCGPP)'s web site. One could also look at the Cochrane Collaboration and search for manipulation or chiropractic. Then there are some conditions that there is a complete lack of evidence. Such as preventing the flu.

As you can see from my long list of quotes on this blog, I am a fan of quotes. Two from Carl Sagan are illuminating in this regard.

"Absence of evidence is not evidence of absence"
- "The Dragons of Eden"

This one is often cited by members of my profession about those things we have no evidence for. For example using chiropractic care to prevent or treat swine flu. While this is true I think what is also important is another quote from Sagan:

"I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence"
- " Broca's Brain"

The claim that spinal manipulation will improve immune function to the extent that it can be used to prevent or help treat the flu is clearly an extraordinary claim. I absolutely believe that it should be researched, just it is not my area of research interest. Some might say why not no harm. Well that is true as long as the public isn't lead to believe that this is a validated treatment. Until the evidence is found, we, the chiropractic profession, have to stop making the claim that chiropractic care will help prevent or treat the flu, which is what the blogger I was responding to wrote. He said that one of the "Sure-fire Strategies to help you and your family respond to the threat of the flu" is chiropractic.

As I wrote before it only serves to marginalize our profession by making us look like we are unscientific.

What I Was Taught In School

Another comment was about how a doctor wanted to believe what he was taught in chiropractic school about an adjustment improving immune function. As I tell my students often do not believe what I tell you. Go to the scientific literature yourself and find the evidence. And if you find that the evidence shows. I would be happy to eat my words that an adjustment will help prevent the flu so show me the scientific evidence.

CDC

One comment about my blog entry was that I suggested that people look at the CDC's web site for advice about the swine flu. The problem with that is supposed to be that "the first thing that website site [CDC's] says is to get the flu vaccine to prevent the flu. We all know that the flu shot is a shot in the dark and far from an exact science"

The problem with this statement is that the CDC does not recommend a flu vaccine for the H1N1 but for seasonal flu. In fact, they say that there isn't a vaccine for the H1N1 flu. Here is what they recommend:

Avoid close contact - Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
Stay home when you are sick - If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness.
Cover your mouth and nose - Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
Clean your hands - Washing your hands often will help protect you from germs.
Avoid touching your eyes, nose or mouth - Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
Practice other good health habits - Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

I know that no chiropractor would have a problem with these recommendations. What does this tell us with the complaint about my suggesting use the CDC for information. It tells us that the person who was criticizing me never even clicked on the links to the CDC to see what the CDC actually recommended. Just as they inferred I had a narrow view of chiropractic, without reading carefully what I wrote, they assumed that the CDC would recommend the flu shot.

As I wrote in the swine flu blog: "Overstating what we know only serves to decrease our credibility." In this case making pronouncements that, all easily available evidence, refutes doesn't do great things for ones credibility either.

SMP

Swine Flu & Chiropractic

2009-05-01T08:03:00.006-04:00

I recently saw a blog that suggests that the second best of the "Sure-fire Strategies to help you and your family respond to the threat of the flu." is chiropractic. Now don't get me wrong, I'd love to be able to say with a straight face and the research to back it up that going to see a chiropractor would help you prevent or even get better from the swine flu, er I mean Influenza A(H1N1) (surely we don't want to insult swines). But honestly I think it is intellectually dishonest and a public disservice to imply that a chiropractor has unique therapeutic tools that will help prevent or treat the flu.

Let's look at the argument in favor of chiropractic as part of how ones family should "respond to the threat of the flu."

Supposedly Ronald W. Pero, Ph.D. performed one of the most important studies that showed the positive effect chiropractic care has on immune function and general health. First the link in the blog leads to an article about the 1917-8 flu epidemic. I'd like to see the original data rather than the owner of that web sites excerpts. Nevertheless it might be true that chiropractic care was better than medical care for the flu in 1917-8. There is a world of difference in the field of medicine between then and now. I hate to say it but I do not think there has been an equally large increase in the effectiveness of an adjustment. In fact I think most traditionalists in my profession would suggest it was as good as it was going to get way back when and we've only screwed stuff up since then.

I searched the National Library of Medicine's online database search system, PubMed to find any published paper by Dr. Pero on chiropractic. I can't find it. Here is that search. Here is another search of just what R Pero published. I read the title of all 183 papers and none appear to be about chiropractic. If anyone can find me the paper, rather than an article in a chiropractic newspaper talking about the research I really would be grateful to find the paper and read it.

Next the blogger discusses a study done at the National College of Chiropractic (now National Health Sciences University) by their then research director, Patricia Brennan. Brennan’s study, if anyone actually reads it, is not really about immune function. It was an attempt to find a physiological marker of active manipulation. The intent was to see if they could differentiate between a sham and real manipulation.

Lots of folks want to use this study to show how chiropractic improves immune function. What is stated: “phagocytic respiratory burst of polymorphonuclear neutrophils (PMN) and monocytes were enhanced in adults that had been adjusted by chiropractors.” is true. So to the true believer in the unlimited wonders of the adjustment this is “proof” that an adjustment improves immune function. Unfortunately, one cannot conclude this from that study. First of all the subjects were healthy normal individuals. We do not know if the response will happen to those who are ill. Maybe when one is ill the response is blunted or eliminated because the PMN’s are already “enhanced” by the need to fight an infection. Conversely, it is possible that the response is enhanced even to a greater degree in the person fighting an infection. We just do not know. Also the response was transient; it was found at 15 minutes but dissipated by 30 minutes after the manipulation. The true believer’s response would be, "so adjust the patient every 15 minutes." That seems logical, except we don’t know if the response is repeatable or if it fatigues. And again it could be more profound as it is repeated, we don’t know. Also we do not know if the increased phagocytic respiratory burst will actually work in any appreciable way to make one better able to defend against an infection or to help the individual get better faster or have reduced effects of the infection that one might have.

The blogger mentions a study done at Life Chiropractic University. There is no such educational institution in the US. The name of the institution is Life University which was Life Chiropractic College. For some reason there are a lot of people who make this mistake. If one googles "life chiropractic university" one finds many chiropractors web pages say they graduated from there. I suggest they take a look at their diplomas.

Regarding this study, I can not comment about any specifics, I haven't read the paper. My only comment is that good research requires replication and if the best we can do is a paper in a defunct journal that is more than 10 years old...

The blog goes on to say that chiropractic improves "And chiropractic care improves the function of the nerve [sic] system through improving the movement of the spinal bones that encase and protect the spinal cord." This is an interesting theory that has been espoused by some in my profession for years. I am aware of no valid research that supports this statement. There is a growing body of good scientific evidence that spinal manipulation can be an effective treatment method for neck pain, headaches and low back pain. Overstating what we know only serves to decrease our credibility.

For information on prevention and treatment of influenza A(H1N1) (swine flu) see the CDC or CDC's flu pandemic web site or MedLine Plus (great consumer oriented health information). Hopefully your chiropractor will recommend these sources of information rather then suggesting that a sure-fire strategy is getting a chiropractic adjustment.

SMP

New CR on Back Pain

2009-04-14T09:51:00.005-04:00

Consumer Reports surveyed people with regards to what helps their back pain. The highest rated treatment was chiropractic care. Here's a video from CBS' Early Show discussing this article.

SMP

Treatments That Don't Work

2009-04-03T10:30:00.008-04:00

If there is a fundamental question in biomedical research it is does a treatment "work". By "working" most people mean is the treatment clinically effective. The first time this question was asked in a rigorous scientific way is often cited as the work of the British Naval physician James Lind, MD (1716 - 1794). Lind, a Scotsman, one might say is personally responsible for the British being nicknamed, Limeys. His research showed that citrus juice "worked" as a treatment for scurvy, which of course we now know is due to a Vitamin C deficiency that the citrus provide a good supply of.

Lind was ignorant of vitamins, which weren't discovered until early part of the 20th century. It is interesting to note that he thought that the cause of survey was putrefied food. So his experiment centered on acidic "foods" to prevent the food one ate from putrefying. He tried having sailors consume the following in six experimental groups : cider, sulfuric acid, vinegar, seawater, oranges and lemon, and a spicy paste plus barley water. In 1753 he published his A Treatise of the Scurvy. Despite his work the addition of citrus to the diets of sailors of the British Royal Navy was not universally accepted. Three lessons we can learn from Lind's work.

Rigorous scientific experimentation can discover effective treatments (ones that "work")
An effective treatment does not validate ones theory about why the treatment is effective.
People will often continue to believe that ineffective treatments are actually effective, even after compelling research has been published.

Dr. David Newman blogs for the NY Times (you've probably guessed I like The Times) writes about believing in treatments that don't work. There is an allure to treatments that one knows or is good at providing. When one starts along the path of evidence based practice one is constantly amazed by both patients and doctors of all types (medical, chiropractic, osteopathic etc.) who continue to use or advocate treatments that compelling research shows are ineffective and sometimes even more harmful than beneficial.

There is a great anecdote about Dr. Paul Glasziou. Dr. Glasziou had published a systematic review (SR) on otitis media (inner ear pain).(1) The most common treatment for this is to prescribe antibiotics. However, the SR found that "watch and wait" is the best approach. So what does Glasziou do when his 2 year old develops acute otitis media? The experience of so many parents and pediatricians with the antibiotics is that the children get better when they take them. Well Glasziou's review suggests that this is because the drug is often given when the pain is at its worst and that the condition will improve shortly on its own. However, doctors and patients ascribe the improving clinical situation to the antibiotics. Thus if we do not know the natural history of the disorder (what happens without treatment) we are all deluded into believing the treatment is what helped the patient. So what did Dr. Glasziou do? He gave his son analgesics only and he got better on his own.(2)

I think what Dr. Glasziou did is a good example of faith. It is faith that the best evidence will in the majority of cases result in the best outcome. Will it every time. No but it is more likely to result in a better outcome than using a treatment that the best evidenced shows is unlikely to help even if personal anecdotes suggest otherwise.

In this blog, Dr. Newman, notes: "More than a half million Americans per year undergo arthroscopic surgery to correct osteoarthritis of the knee, at a cost of $3 billion." This is despite a rare type of research study. The study was a placebo controlled clinical trial of surgery. This means that people who were not in the treatment group still had surgery but surgery that wasn't effective. The results showed a comparable outcome in both groups. Thus, the surgery that so many Americans are having is worthless.

What is interesting about this study using placebo surgery is that the last time placebo surgery was used the outcome was the same that the surgery was no better than placebo.(3) This was in the 1950s with a procedure that at the time was thought to be the best treatment for angina pectoris, internal mammary artery ligation. Some people say that the beginning of evidence based practice was with the publication of two placebo controlled studies comparing internal mammary artery ligation and sham operation for angina pectoris. After the publication of these two studies the use of this well loved procedure went away.(4, 5)

The Obama administration proposes that in health care reform that we place evidence ahead of belief, anecdote, profit, etc. Unfortunately, I fear that the First Amendment will get in the way. The right "... to petition the Government for a redress of grievances." I fear that lobbing will trump evidence.

SMP

Finding a Good Chiropractor

2009-04-03T09:16:00.006-04:00

I just read a blog that critiqued a paper by Redwood and Globe. This blogger seems to live in a different chiropractic planet than I do. He believes that chiropractors should be allowed to turn patients into annuities for doctors, that is put them on extended care plans which have not been shown to be beneficial to the health of the patient.

According to Astin's, work published in JAMA, many people go to chiropractors and other CAM providers because they believe that health comes from inside our bodies not from outside. Not really a bad idea, as authors of a new study in the on-line journal PLoS Medicine report on the how much diet and lifestyle contribute to chronic disease or death. Nevertheless some of my peers seem to successfully morph a person's desire to be more self reliant with regards to their health but convincing them that getting an adjustment, a spinal manipulation, will somehow help their body to function better.

My co-authors and I have written about these beliefs in a paper about mainstreaming chiropractic. Also in the open access journal, Chiropractic and Osteopathy, I am an associate editor of C&O, is a new paper about how to choose a good chiropractor. While this paper is about finding a good sports chiropractor, I think its findings are ones that should be applied to finding a good chiropractor in general and extended treatment plans are not part of the formula for a good chiropractor.

SMP

More nuts

2009-03-16T08:53:00.006-04:00

The NYTimes now reports on a treatment for peanut allergies using...peanuts. This information comes from two abstracts reported at this weekend's American Academy of Allergy, Asthma & Immunology annual meeting (see abstracts #576 & 665 - free PDF). In case someone thinks this is weird that I've blogged twice on peanut allergy - my interest in this was created by the serendipitous meeting with an NIH researcher.

SMP

The Medical Profession weighs in on the Stimulus Package

2009-03-10T09:55:00.003-04:00

The allergists voted to scratch it, and the dermatologists advised not to make any rash moves.

The gastroenterologists had sort of a gut feeling about it, but the neurologists thought the administration had a lot of nerve, and the obstetricians felt they were all laboring under a misconception.

The ophthalmologists considered the idea shortsighted; the pathologists yelled, "Over my dead body!" while the pediatricians said, 'Oh, Grow up!'

The psychiatrists thought the whole idea was madness, the radiologists could see right through it,

Chiropractors didn’t think the Congress had the spine to back it and the spine surgeons decided to wash their hands of the whole thing.

The internists thought it was a bitter pill to swallow, and the plastic surgeons said, "This puts a whole new face on the matter."

The podiatrists thought it was a step forward, but the urologists felt the scheme wouldn't hold water.

The anesthesiologists thought the whole idea was a gas; and the cardiologists didn't have the heart to say no.

In the end, the proctologists left the decision up to the assholes in Washington...

Stroke of genius

2009-03-03T00:47:00.004-05:00

I have discovered a real stroke of genius. If one says often enough and has enough money to put billboards up that a chiropractor caused a stroke, then it must be true. Madison Ave. discovered this years ago.

Here's a news piece about the billboards and the women who put them up.
http://wcbstv.com/topstories/stroke.chiropractor.billboard.2.948444.html

(BTW there is no such word as chiropractry as used in the CBS news piece - they must have forgotten to use a spell-checker)

Surely if these billboards are up there must be some truth to it, no? Well if you asked me the question about a year ago I would have said, yes there does appear to be a risk of stroke after seeing a chiropractor. I have advocated that even though the odds were one in five hundred thousand treatments to one per five million treatments that one should still tell prospective patients about this small risk.

But then a huge study was published early last year.

Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, et al . Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008;33(4 Suppl):S176-83.

Cassidy et al have found that the likelihood of having a stroke after seeing a chiropractor is the same as the likelihood of having a stroke after seeing an MD. Thus, the previous research that had found an association between chiropractic care and strokes were showing only half the picture because they didn't look at whether the association existed with other professionals. The problem isn't the intervention it is that one seeks care from a health professional. This is sort of how some advertisements work.

4 out of 5 ______ like this product. They don't tell you that 4 out of 5 are just as happy with the competitor's product. I've blogged on this before (see Katz and dogma) but I figure if repeating something that isn't true over and over will improve the odds that it will be believed maybe my stroke of genius is to repeat what is true.

It is critical to understand that association does not establish causation. If association did let us know what caused something then think about this. When one sees a photograph or video of a house fire in the news media one always sees fire engines. One might conclude that fire engines are there to cause the fire (as they are in Ray Bradbury's book Fahrenheit 451).
On the health front at one time research clearly showed the association between salt intake and hypertension. Eventually, it was discovered that salt intake isn't the culprit, it's fats and other elements of a poor diet. The reason salt looked as if it was the cause is because in the U.S. fatty foods tend to be salty, think french fries.

Well this stroke issue is looking similar to salt. The reason some people have strokes after seeing a chiropractor and a medical doctor is because they have the early symptoms of an event that may lead to a stroke and those symptoms send them to a doctor's office (be that a chiropractic or medical doctor).

In a way this is also similar to the issue of autism. Parents have what appears to be a normal child, the child gets immunized and then they notice abnormal behavior that turns out to be part of autism spectrum disorder. Did the immunization cause the autism. The best evidence says no but the parents searching for some reason for their child's behavior grasp at the immunization as the cause.

Similarly, the person who has a stroke grasps for a cause, and if they saw a chiropractor a malpractice attorney is often ready to say that the cause is the chiropractor.

Does this mean that chiropractic care is completely without any complications. Clearly any treatment that has the power to help has the power to hurt. It is just the best evidence right now doesn't support the association between cervical manipulation (usually done by chiropractors but now more and more PTs, MDs and DOs are doing this) and stroke.

What is really interesting about this whole campaign against chiropractic care is that the campaign isn't about cervical manipulation, which some PTs, MDs and DOs do it is about chiropractic cervical manipulation only. Granted DCs use spinal manipulation more than any other type of health professional and perform the vast majority of manipulative procedures, still why don't the people with the billboards and other media say cervical manipulation may cause a stroke instead of saying chiropractic might cause a stroke? This is another critical question because IF there was a problem with cervical manipulation is it only at the hands of a DC. There is one study that critics of chiropractic have often cited to show the risk of chiropractic care. This study from Germany purports to report on vertebral artery dissections after chiropractic care. Unfortunately for those who use this as evidence of chiropractic's harm only 11% of the subjects in this study were treated by chiropractors but 50% were treated by MDs and 14% by PTs. But to read the title or abstract alone one would be convinced that it is about care provided by chiropractors. Here's the citation (if you click on the link you can read the abstract):

Reuter U, Hamling M, Kavuk I, Einhaupl KM, Schielke E. Vertebral artery dissections after chiropractic neck manipulation in Germany over three years. J Neurol. 2006 Jun;253(6):724-30.

Again if the people who put up the billboard were concerned with public safety why put up billboards that say chiropractic rather than cervical manipulation?

SMP

Pot calling the kettle black

2009-03-03T00:36:00.007-05:00

When I started chiropractic college chiropractors were, according to the AMA, an "unscientific cult". Heck, some essentially still say that (see my Blog entry on Katz and Dogma). Nevertheless, Sharon Begley's column in Newsweek points out that standard medical practice is often unscientific. Looks like the pot calling the kettle black.

But I figure a double standard is the norm, and just get over it.

SMP

Chiropractic & Osteopathy

2009-02-18T15:17:00.009-05:00

It was announced this week that Chiropractic & Osteopathy will be in CINAHL Cumulative Index to Nursing and Allied Health Literature, is the most comprehensive resource for nursing and allied health literature.

C&O is an open access, peer-reviewed online journal that aims to provide chiropractors, osteopaths and related health professionals with clinically relevant, evidence-based information.
I serve as an Associate Editor for C&O
SMP

Killer Peanuts?

2009-02-18T09:18:00.009-05:00

No this isn't about the tainting of peanuts with Salmonella, this is about peanut allergies. A couple of years ago I was waiting for a flight out of Washington and struck up a conversation with a man sharing a table with me. He was a dentist now working full time at NIH. He told me he was working on a project that was attempting to stem the tide of the epidemic of peanut allergies.

My two children do not have the allergy but we've been affected by it because of children with the allergy in their schools. There are no peanut classrooms, no peanut lunch tables etc. I used to like getting peanuts on air flights but not any more. In fact I have no recollection of any talk about peanut allergies during any of my years in public school (ending in 1975). The epidemic of peanut allergies is relatively new and has changed much in America. But where did it come from?

This NIH researcher told me that in Israel peanut allergies are almost non-existent. The theory is that because one of the first solid foods Israelis give their children contains peanuts. It is called Bamba and is sort of like a Cheese Doodle or Cheetos with peanut flavor instead of cheese. While so many Americans feed their infants Cheerios as one of their first foods for Israelis it is Bamba. In the US for a long time parents have been admonished to keep their infants away from peanuts.

He told me that NIH was now funding a study to see if children feed peanuts early in life are less likely to get the allergy. The NY Times recently reported that early results suggest that early exposure to peanuts reduces the risk of peanut allergies.

The study, By Du Toit et al. was published in November of 2008 and compared the risk of peanut allergy amongst Jewish children in the UK to those in Israel. By using only Jews the researchers eliminated the possibility any differences were due to differences in ethnicity. They found a 10 fold increase in the likelihood of having peanut allergy amongst the children from the UK.

I guess my mom didn't harm me by giving me peanut butter when I was an infant. Maybe we need to bring back Mr. Peanut

SMP

Plateletes

2009-02-17T16:43:00.006-05:00

The NYTimes recently published an article on platelets as a soft tissue treatment. ABC News also did a piece on this use of platelets to treat soft tissue problems. Back in 1993, I was at an orthopedic grand rounds at Yale where the speaker was Albert Banes, PhD. Dr. Banes has done pioneering research on what stimulates fibroblasts to multiply and synthesize collagen (collagen is needed to repair soft tissue injuries). His work has shown that intermittent loading (application of force) stimulates both replication and synthesis in fibroblasts. He also talked about how platelet bound growth factor also does this.

Dr. Banes related an anecdote that is similar to these stories. He talked about how an orthopedist at UNC, where Banes worked had chronic patellar tendinosis that was refractory to treatment. The doctor, a triathlete had suffered with the pain for over a year. Banes suggested based upon research they were going to do that the orthopedist get his own blood spun down and inject his tendon with his own platelets. This eliminated the symptoms in less than a week.

I've been teaching, for a few years, a treatment, Graston Technique that research also shows stimulates fibroblasts to replicate and synthesize collagen.

SMP

Court Ruling on Vaccine and Autism Link

2009-02-14T22:00:00.008-05:00

A federal vaccine compensation court recently ruled that the MMR (measles, mumps rubella) vaccine does not cause autism. This case is very important because of the standard the court used to make its decision. As opposed to criminal cases where the standard is "beyond a reasonable doubt" this special court used "preponderance of evidence" as the standard. The judge, called a "special master", George L. Hastings, Jr ruled that the evidence was overwhelmingly contrary" to the argument made by the parents seeking compensation in this case. In fact he said that the family had been "misled by physicians who are guilty, in my view, of gross medical misjudgment."

The point is that those who have been telling parents of autistic children that the cause is vaccines are really the problem here. In fact, I think they are no different than those who claim the holocaust didn't happen or the flat earth society members who claim NASA never went to the moon. They create a controversy where none actually exists. Unfortunately, the media at times accepts deviant viewpoints as the "other side of the coin" and gives them the opportunity to present rebuttal, when they have no more valid a point than holocaust deniers or flat earthers do.

I know that a lot of my colleagues have a different opinion. Many chiropractors are as opposed to vaccination as religious zealots are to evolution. They cite specious research and ignore valid studies that refute their point. I understand why they have this position, even if I reject it out of hand. They tend to have anti vaccination positions for what they believe are good reasons.
Their experience is that the AMA ignored evidence that chiropractic care can be quite helpful when they engaged in an illegal boycott of the chiropractic profession (see Wilk v AMA). Thus, many in the chiropractic profession recall this history and do not trust medical research, especially when it contradicts their one of our basic philosophies, that nature is the best medicine. Then of course there is all that anecdotal evidence which just reinforces the distrust of medical interventions.

Saying I understand where the anti-vaccination beliefs come from doesn't mean I agree with them. In my ethics column in Dynamic Chiropractic, I've written about the ethics of being opposed to vaccinations. This ethics column resulted in the most hate mail (hate e-mail) I've ever received from my peers. One, a former student suggested I help my profession by killing myself. This type of argumentum ad hominem is common when one attacks ideas in my profession. Unfortunately, despite the talk of chiropractic philosophy (philosophy is the love of learning), free thinking often isn't loved too much. BTW there is better evidence now that suggests that cervical manipulation does not cause stroke.

SMP

Need x-rays (or CT or MRI)?

2009-02-07T08:10:00.010-05:00

Many healthcare providers operate under the aphorism "to see is to know" and order spinal x-rays or MRI immediately upon seeing a patient with low back pain. This week the venerable British medical journal The Lancet published a systematic review and meta-analysis concerning imaging and low back pain.

Systematic Reviews and Meta-analyses
A systematic review is a type of paper wherein the authors search the biomedical literature (research) for every paper on a topic. They use a plan that details how they will search and what factors about a study should cause it to be used or not used in their review. Then they use a detailed method to determine the quality of the study. Not all research is done equally well so the studies must be critically appraised, tossing out those studies that have fatal flaws in their design. This is a systematic review. The remaining studies are then subjected to a meta-analysis. A meta-analysis is done by collecting data from the remaining high quality studies and essentially pooling them statistically into a single larger more robust study. As poker has a hierarchy of more important hands (e.g. 3 of a kind beating a pair) with scientific research there is a hierarchy and systematic review and meta-analysis are the research equivalent of a royal flush in poker.

From the study's abstract:

Interpretation Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

By lumbar imaging the authors of this study mean x-ray, CT & MRI. Does not improve clinical outcomes means that getting the imaging studies does not help the patient get any better. Thus, they found from the research that has been published is that patients with acute or subacute low back pain who did not have indications of serious underlying condition there was no difference in the way the patient's felt whether they had imaging or not. Simple thought, if doing the imaging study, which takes both time and money and if radiographs or CTs exposes one to radiation, but does not result in a benefit why do them?

What are the "indications of serious underlying conditions"?

History of cancer
Rapidly progressive or severe neurologic deficits - loss of muscle strength, fecal incontinence, and bladder dysfunction (incontinence or retention)
Potential infection - fever, intravenous drug use, or recent infection
Vertebral compression fracture - older age, history of osteoporosis, and steroid use
Ankylosing spondylitis - younger age, morning stiffness, improvement with exercise, alternating buttock pain, and awakening due to back pain during the second part of the night only
Some organic diseases - pancreatitis, nephrolithiasis, aortic aneurysm, endocarditis or viral syndromes,

There are those who might say that these guidelines do not apply to chiropractors because we look for other important things on radiographs. Well about a year ago a group of chiropractic radiologists came up with essentially the same spinal diagnostic imaging guidelines. Why did the chiropractic researcher find the same thing as medical researchers? Because modern chiropractors and modern medical doctors use imaging for the exact same purpose - to ensure that the patient does not have a serious underlying disorder which isn't likely to respond to non-surgical management. For the vast majority of people with acute/subacute low back pain non-surgical management is best, imaging doesn't improve the patient's outcome (one doesn't get better faster or improve more) and doctors of chiropractic are the non-surgical spinal specialist. See the latest evidence on low back pain spinal manipulation from the World Health Organization's task force for the Bone and Joint Decade.
So if your doctor (MD or DC) is rushing to do diagnostic imaging when you have acute low back pain. Maybe, just maybe you need to find a doctor who is practicing with 21st century knowledge. How to find such a doctor? One source is the NCQA Back Pain Recognition Program. One might also look at the member ship of T he West Hartford Group, Inc

SMP

Fibromyalgia

2009-02-02T09:04:00.005-05:00

I just saw an advertisement in my local newspaper for a seminar a chiropractor was running on chiropractic treatment of fibromyalgia syndrome (FMS).
This is an issue that is dear to my heart because not only do I lecture on fibromyalgia but I have also published on this.

Schneider MJ, Brady DM, Perle SM. Commentary: differential diagnosis of fibromyalgia syndrome: proposal of a model and algorithm for patients presenting with the primary symptom of chronic widespread pain. J Manipulative PhysiolTher. 2006 Jul-Aug;29(6):493-501.

Our paper is available for free, click on the link above.
In our paper we basically deal with the fact that there are three classes of conditions that are commonly misdiagnosed as FMS.

Medical Conditions - a competent diagnostic work up must be done to rule out some other cause for the patients widespread pain for example: Hypothyroidism, anemia, rheumatoid arthritis, Lyme disease, rheumatic auto-immune disorders such as ankylosing spondylitis or scleroderma, multiple sclerosis, and occult malignancy
Functional Metabolic Disorders - these are subclinical disease states and disorders involving dysfunction of internal organs and metabolism, rather than true pathology
Musculoskeletal Disorders - various conditions while documented in the literature are not known universally, for example joint dysfunction (a name for the joint that causes symptoms which resolves after manipulation), myofascial trigger points or sclerotomal pain. Murphy et al present a good diagnosis-based clinical decision rule dealing with how to diagnose these conditions.

Now one might say that the last category should be within the competency domain of all chiropractors. For various reasons (e.g. where they went to school or their anachronistic beliefs about chiropractic) some are ignorant of all the potential conditions that may look like FMS but really only are these muscuolskeletal dysfunctions.
Now the point of this blog. There is compelling evidence at this time that FMS is not a condition of the musculoskeletal system. Clearly it is pain in the musculoskeletal system but that does not mean that there is anything wrong with the musculoskeletal system just that is how our brain interprets the symptoms.
For a good review of the pathophysiology of fibromyalgia see:

Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. 2007 May 15;146(10):726-34.

Abeles et al review on fibromyalgia is available free just click on the link above.
The basic problem with FMS is a change in how the brain perceives touch and interprets it as pain. Thus, treatments geared towards affecting any changes to the periphery (e.g., muscles, joints, ligaments) are not likely to benefit the patient with FMS. Aerobic exercise (which involves using these peripheral tissues) is beneficial because of its mood elevating effects.

The patient with "FMS" who finds that manipulation, massage, vitamins & other supplements is an effective treatment more than likely had successful treatment of some other condition that was misdiagnosed at FMS. I guess for that person they are lucky that the stumbled upon someone who mis-treated their misdiagnosed FMS. The real problem is the vast number of people with real FMS who stumble along between health care providers who haven't correctly diagnosed FMS or who have but offer inherently ineffective treatments.

SMP

A healthy skepticism - scoliosis

2009-02-01T10:28:00.004-05:00

A few years ago there was a lot of buzz about a "new" treatment for scoliosis. It was the Copes Brace. I saw a bunch of advertisements for this in chiropractic trade papers. I heard people talk about it glowingly at non-scientific meetings. A say "non-scientific meetings" becuase I never saw a single study or presentation at a peer-reviewed conferece. It all seemed like hype to me and as if the brace was nothing more than a new packaging of a Boston brace with a specific bit of marketing towards chiropractors. Well interestingly the "developer" just got jail time in Lousiana for insurance fraud becuase he was practicing without a license. The developer of this method did not hold any health care licenses. See:

http://www.2theadvocate.com/news/38738672.html

When my former students asked me about this method I always suggested a healthy dose of skepticism. I've found that often the bigger the hype the smaller the validity.

SMP

Katz and dogma

2009-01-29T10:26:00.004-05:00

I was talking to a friend today and she brought to mind an exchange between Murray Katz, MD and me from the McGill University, Faculty of Medicine, Continuing Medical Education discussion board. I thought that I would post some of it here.

Dr. Katz had presented an anti-chiropractic diatribe at McGill which is "so full of fabrications, extrapolation and cherry-picked use of the literature that his presentation really should be prefaced with a warning that this is fiction."

I was asked a question on the discussion board after posting the comment above (and more) about "high neck manipulation." I cited the recent literature on the topic:

Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, et al . Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008;33(4 Suppl):S176-83.

This is rather compelling evidence that the association seen in previous studies between cervical manipulation and vertebrobasilar stroke was actually an association between vertebrobasilar stroke and seeking the care of a health care professional. We know this from Cassidy et al because the association between stroke and seeing a chiropractor was identical to the association between stroke and seeing a primary care physician (PCP) AKA a medical doctor. Thus manipulation was not associated with stroke just seeking care was.

Then Katz joined in the discussion:

Re: High Neck manipulation Posted by Murray on Jul 23, 2008 9:38
The comment on various studies by Mr. Perle (with all due respect none of his many degree were obtained under the direction of a Faculty of Medicine) are typical of the chiropractic “spin”. There are endless studies on homeopathy but there is more urine from a shark swimming on Mars than the ingredients on the bottle. Likewise, this is no such thing as chiropractic vertebral subluxations. The study he quotes using billing numbers is typical of chiropractic studies which Wallace Sampson and J. William Kinsinger wrote about in their paper “Producing Quack Studies for Quackery”. To show the extent of this quackery, a German study using actual hospital records and also going backwards found 36 cases of chiropractic stroke. Chiropractors want us to waste our time discussing their studies. There are a few chiropractors who have crossed over to science. These admit freely there is no such thing as subluxations. They no longer claim to have meaningless degrees. They start with the basic question, why are 200 million high neck manipulations a year being done on everyone from newborn babies to senior citizens. What is the diagnosis? The following commentary was published last week in the Calgary Herald in Alberta. It deals directly with the issues. Re: "Anecdotes are not enough to condemn chiropractors," Susan Martinuk, Opinion, July 18. Susan Martinuk's column is typical of chiropractic spin. Seventy years of scientific literature from all over the world, the warnings of neurologists all across Canada, three coroners' reports involving the deaths of three young women in Canada as well as an endless number of life-devastating strokes are not anecdotes! Almost without exception, all of these victims of chiropractic neck manipulation stroke and death have a number of things in common. They did not have pain in the highest neck area. They had their highest neck manipulated with the diagnosis of vertebral subluxations, something which does not exist. No one should die or live a disabled life for a condition that does not exist. Highest neck manipulation was done on them at almost every visit no matter what the complaint, sometimes 50 or 100 times, or more. Does it ever work? From newborn babies to senior citizens, Albertans are being told they have vertebral subluxations and need to have the highest neck manipulated. This is a scam and a fraud paid for out of the public purse and your own pockets. Victims and physicians are asking for six reasonable and scientific restrictions to be placed on all chiropractic highest neck manipulation. None of these will prevent the use of scientific manual therapy for neck pain, most of which is done responsibly by physical therapists. These restrictions are that highest neck manipulation should not be done on babies and children, not for claims that this can provide "wellness" to the body, not 50 times on the same person, not to claim to treat liver, heart or other organ diseases and most important, not for the claim that there are vertebral subluxations in the highest neck area. Physical therapists abide by these restrictions and hence have no strokes or death due to neck manipulation. The Minister of Health of Alberta has already been warned to enforce these restrictions and since Sandra Nette's stroke, we now have another case in Alberta of a young man who suffered a locked-in stroke and has come partly out of it. There are others. The reason the College of Chiropractors of Alberta, there to supposedly protect the public, will object to these sensible restrictions is that their officials all believe in this quackery. In my own experience, I was placed on a table from which a part suddenly dropped away and as a result, I had a stroke. The College of Chiropractors fully supports such quack machines claiming they can treat neck pain? Never allow a chiropractor to place you on a drop table machine. In the words of the Wellness Center in California, never agree to neck manipulation. Diana Dingley, Chestermere, (a stroke victim), and J. William Kinsinger, MD, Edmond, Okla. © The Calgary Herald 2008

Here is my reply:

Re: Re: High Neck manipulation Posted by Stephen on Aug 02, 2008
7:08

Dear Dr. Katz,

It appears to me that somehow having a medical degree has conferred upon you a level of arrogance that most other professionals do not possess. Who gave you the right to determine who has or does not have a valid doctorate? I think that government has that prerogative and it has spoken in Canada, despite your views. By your thinking, I ought refer to you as Mr. Katz because, with all due respect, none of your degrees were obtained under the direction of a Faculty of Chiropractic. This rather juvenile of you don’t you think?

You write that “few chiropractors who have crossed over to science”. I searched pubmed and cannot find a single paper in the peer reviewed literature that you have authored only one letter to the editor. This sounds as if the pot is calling the kettle black. Your degree and likewise your comments do not provide me with evidence that you have “crossed over to science”. Coming from a scientific profession does not mean one is scientific. One actions and words speak louder than ones degree.

On the other hand my publishing record in the peer reviewed and pubmed indexed literature is available.

http://tinyurl.com/6y34tf

Likewise one can find my writings on ethics within chiropractic.

http://www1bpt.bridgeport.edu/~perle/ethics.htm

http://www.acatoday.org/level2_css.cfm?T1ID=15&T2ID=160

And finally I am quite clear when it comes to subluxations.

http://www.chiroandosteo.com/content/13/1/17

I suggest you read what I have published and stop assuming I defend bad chiropractic practice, any more than I should accuse you of defending bad medical practice.

Of interest is the fact that the Cassidy (1) study I cited is published in the preeminent orthopedic journal. I can’t find Sampson and Kinsinger’s paper in pubmed. I guess it wasn’t published in quite as prestigious journal. One wonders what the scientific world has come to when such an important work is relegated to the scientific backwater and the quack studies of quackery that use billing records written by people with meaningless degrees is published in such a prestigious journal. Or maybe Dr. Katz’s view of the world is a bit askew.

Cassidy’s (1) study is a population based study rather than a retrospective review of hospital records of some hospitals, which the German study (which Dr. Katz alludes to but does not cite (2) is). It turns out that in the German study 50% of the so-called “chirotherapy” was provided by orthopedic surgeons and only 11% was provided by chiropractors. (2-3) I would suggest Dr. Katz, when using a study to cite the hazards of chiropractic care one should carefully read the study to ensure that the so-called chiropractic treatment was actually provided by chiropractors and not medical doctors.

One could debate the merits of each study but that does not appear to be what Dr. Katz would like to do. His modus operandi appears to be ad hominem attacks, the use of spurious literature, misquoting his own sources and “scientific” debate via newspaper. This is not an exercise I choose to engage in any longer. If the level of debate rises to a professional level, I shall respond appropriately.

Stephen M. Perle, D.C., M.S.

[1] Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83.

[2] Reuter U, Hamling M, Kavuk I, Einhaupl KM, Schielke E. Vertebral artery dissections after chiropractic neck manipulation in Germany over three years. J Neurol. 2006 Jun;253(6):724-30.

[3] Wenban AB. Inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' in the peer-reviewed biomedical literature. Chiropr Osteopat. 2006;14:16.

If anyone is interested in the whole exchange please go to McGill's web site

Again if anyone is interested in the best evidence on chiropractic stroke read the study by Cassidy et al

SMP

An inauspicious beginning

2009-01-28T08:45:00.002-05:00

As they say a journey of a million miles begins with one step.

However, what motivates me to start writing results in an inauspicious beginning for my blog. I found out that one of my former students just pled guilty on Jan 22, 09 to insurance fraud

This makes me ponder what makes someone steal, what fundamentally is so little money (think Madoff ponzi scheme). I know that some will read this and say half a million dollars is a lot. But think about this. Since that money was stolen by committing insurance fraud, the money was reported to the IRS by the insurance company. Thus, after all the taxes this might have resulted in a net of $300K. It appears that the fraud was committed from 2005 - 2008. Thus, $100K/year.

I know that this is a little more money than the median family income in Simsbury, CT where the fraud took place. I say it is not that much money because of how great the downside risk was. In this case, the doctor not only has to repay the money but could end up going to jail for 10 years and could pay up to a quarter of a million dollars in fines. As a gamble the downside risk was way too high given the pay-off ($300,00).

Not that any amount of money would motivate me to steal but at least if he'd stolen many millions or billions he could have squirled away enough money in an off-shore account that when he got out of jail he'd be able to live well in a third-world country. In this case, I suspect when he gets out of jail he will have no money and no real prospects to earn money. If he has a family I suspect they are financially ruined. They might loose their home (as many honest people are right now) but at minimum they will loose, what no doubt, was a comfortable lifestyle.

This is a sad outcome for the doctor's family (who I am sure were innocent) and all who knew him. If I could have prevented the fraud, I would. However, given that the fraud actually occurred, I am actually glad that it was discovered and justice prevails.

For the chiropractic profession, fraud like this only serves to erode the profession's social and cultural authority. Thus as a chiropractor I condemn this fraud and applaud the FBI and the US Attorney's office for this successful investigation and prosecution.

SMP

Perles of Wisdom Or NOT

2008-09-12T15:48:00.001-04:00

Whether the content of this blog are words of wisdom or not will, of course, depend upon ones point of view.

As they say "great minds think alike." But I like to keep in mind the corollary"fools seldom differ."

SMP