Thursday, December 16, 2010

The self-importance of being Ernst

Oscar Wilde memorial, Dublin, Ireland.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.


  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
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  1. Oh my God Stephen, this is phenomenal!

    It is poetic and sadly so true it hurts.



  2. Unfortunately, sounds more like an axe to grind than science.

  3. Well done Stephen! The gods know that the chiropractic profession has its share of problems and questionable practitioners but Ernst has really painted himself into a corner and comes off looking like …umm … a quack.

  4. Excellent article Stephen. Thanks for all of your work and dedication to our profession.


  5. Wow! Very interesting looks at the work of someone who is far too interested in discrediting chiropractic. I wonder what ticked Ernst off so much that is life's work revolves around trying to destroy the chiropractic profession?

  6. A devastatingly accurate analysis of Ernst’s self-righteous crusade to bury all healthcare techniques he doesn’t like. Phenomenal!

    --Bill Lauretti, DC

  7. A couple of people have privately emailed me about the proper citation for Ernst's paper in Verlag Perfusion GmbH. I stand by my statement that citing this as Perfusion is not appropriate as there is a journal of renown by that name.

    A few have noted that verlag is German for publisher or publishing house. And GmbH is an abbreviation for the German Gesellschaft mit beschränkter Haftung, which in English means company with limited liability. I knew these facts.

    I've said that one should cite the journal as Verlag Perfusion GmbH because that is what the copyright notice at the bottom of the pages says.

    On the other hand The British Library calls the journal Perfusion -Munich then Nurnberg.

  8. Your criticism of Dr. Ernst’s citation of the testimony of Preston Long, DC, is misinformed. The Campaign for Science-Based Healthcare (SBHC) was granted intervenor status at the hearing before the Connecticut Board of Chiropractic Examiners (“Board”). As President of SBHC I had access to all documents filed and participated in the hearing. On September 14, 2009, the Board issued a “Ruling on Request for Status and Notice Regarding Procedures” which provided, in pertinent part: “In lieu of live direct testimony, all parties, intervenors and other designated persons must prefile their testimony by October 27, 2009.”

    In accordance with the Board’s ruling, Preston Long, DC, who had been granted intervenor status by the Board, submitted his prefiled testimony on October 25, 2009. This filing is reflected in the Board’s “Declaratory Ruling Proceeding Regarding Informed Consent EXHIBIT LIST,” as Exhibit 42: “Preston Long, DC - Prefiled Testimony, October 25, 2009.” As required by the Board, the original and seven copies of the prefiled testimony were sent to the Board and served on all parties and intervenors. Thus it is entirely correct that Dr. Ernst referred to this document as Dr. Long’s “testimony.” That is the name of the document and it is how the Board itself referred to the document. Nowhere does Dr. Ernst say that Dr. Long’s testimony was part of the actual hearing. His only errors were referring to an administrative proceeding as a “court,” and in describing a filing as a “presentation,” which is fully understandable given that he is not a U.S. resident and therefore likely unfamiliar with the American administrative procedural systems, of which there are 50 in the individual states plus one federal system.

    Because Dr. Long could not appear in person before the Board at the hearing to attest to his prefiled testimony the Board did not admit the testimony into evidence nor would it allow a substitute witness to adopt the testimony. This was the Board’s decision and is not correctly described as “in accordance with the procedural rules in CT.” In fact, the Board ruled exactly the opposite when the International Chiropractors Association requested that David Cassidy be allowed to substitute for its previously designated witness, thus demonstrating that the decision was a discretionary one, not required by any “procedural rule.”

    I don’t know who told you the documents were not to be “made public,” but there was never an order issued by the Board to that effect. In any event, that is not the same thing as the document’s not being part of the public record nor does the fact that the Board refused to consider Dr. Long’s testimony mean that the document is not part of the public record. In any event, whether it is or is not part of the public record is irrelevant. Copies of Dr. Long’s testimony were in the hands of all participants in the Board hearings and there was nothing wrong with anyone sending a copy to Dr. Ernst for his consideration. Thus, your insinuation that Dr. Ernst’s possession of Dr. Long’s testimony is somehow inappropriate is simply not in accordance with the public record of the Board’s proceedings.

    Jann J. Bellamy, J.D.
    Campaign for Science-Based Healthcare

  9. That prefiled testimony isn’t testimony until the board has its hearing. And according to the Regulations of the Department of Public Health 19a-9-29 (e) the person submitting the testimony must be present and adopt the testimony. Long wasn’t present therefore he couldn’t adopt the testimony and it was not admitted. I could be wrong but testimony that isn’t admitted as testimony is no testimony at all.

    Ms. Bellamy says that the fact that Long’s testimony wasn’t accepted isn’t in accord with the procedural rules in CT. I guess because she isn’t from Connecticut she didn’t bother reading the Rules of Practice. Probably because she was a layperson intervenor and now wants to claim knowledge of legal proceedings in CT. From Regulations of the Department of Public Health 19a-9-29 (e) “each witness shall be present at the hearing at which the prefiled written testimony is offered, shall adopt the written testimony under oath and shall be available for cross examination as directed by the presiding officer.”

    Regarding the ICA having Cassidy represent them and not allowing someone else to adopt Long’s prefiled testimony. Long was an intervenor as an individual and the ICA was a party as a corporation. Thus Long was the only person who could represent Long but the ICA could pick anyone they so choose to represent the corporation. They choose Cassidy.

    The problem with Ernst having a copy is as a scientist writing a paper whose purpose is “summarising all fatalities which occurred after chiropractic spinal manipulation and were published in the medical literature” it had no probative value. And not that I am a conspiracy theorist but Ernst’s façade of disinterested objectivity is shattered when he uses material sent to him from zealots for whom science is a dilettante's game. You were the one who during their testimony said that you ignore research that doesn’t support your conclusion. While this is normal practice in legal research – not presenting to the court opinions that don’t support your case – it is bad science and suggests that as the mouthpiece for the Campaign for Science-Based Healthcare (SBHC) you ought to get to know science a bit better.


    19a-9-1 (13) "Intervenor" means a person, other than a party, who is allowed to participate in either a contested case or a hearing on a request for declaratory ruling, as set forth in section 4-177a of the Connecticut General Statutes, and section 19a-9-27 of the Regulations of Connecticut State Agencies.

    19a-9-1. (17) "Party" has the meaning provided in section 4-166 of the Connecticut General Statutes.

    Connecticut General Statutes, Title 4, Chapter 54, § 4-166 - Definitions
    (9) "Person" means any individual, partnership, corporation, limited liability company, association, governmental subdivision, agency or public or private organization of any character, but does not include the agency conducting the proceeding;

    DPH regulations

  10. Excellent post and response to Ms Bellamy's comment. I recall Dr. Long's pre-filed submission was rejected because he was unable to appear in person, attest under sworn oath that it was accurate, and then endure cross examination. As a result his submission was kicked aside and does not appear in the official record or transcripts and was never deliberated upon by the Board of Examiners. If the CBOE ruling were to be appealed to Superior Court the judge would not consider Dr. Long’s pre-filed submission as part of the proceedings. Dr. Long’s submission was never qualified as actual testimony and therefore should not be cited as such by Ernst.

    Truth be told the involved parties were looking forward to Dr. Long testifying and were disappointed at never having the opportunity to cross examine him.

  11. Great expose on Ernst and the self-acclaimed perceived authority in the field - unfortunately, those important nuances don't reflect fairly in headlines, and the situation does reflect a disappointing abuse of the term "scientific". It goes without saying that the sheer number of published papers he's authored (a distracting indicator of lucidity) might deflect one's observation from a humanistic one - that he could be under the influence of cognitive decline, as in dementia...presenting as irrational associations and narcissistic behavior. Whatever it is, something ain't right about it.

    Aaron Root, DC, DACNB

  12. Thanks for the reminder that not all scientific publications or authors are created equal, and bias can crop up anywhere.

  13. A well-constructed addition to the demolition of Dr Ernst. It is staggering that his pseudoscientific manipulation of data has been published on so many occasions (ignoring the journal he is affiliated with, of course, as one would expect him to publish his own drivel, after all). What really makes me chuckle is that while he's rambling on about non-existent associations we can continue to get on with some proper work, namely getting our patients better!

    Thanks for your work on this and other articles.

    S Garstin DC