I recently attended the cervicogenic headache conference in Las Vegas. The keynote speaker was Nicki Bogduk, MD, PhD. Our profession was honored to have Howard Vernon, DC, speak. He told me following Bogduk was the hardest thing he had ever done professionally. The audience was comprised of 130 physicians (30% chiropractors). Bogduk explained that he felt most exam procedures were a waste of time; that more physicians should go back and relearn their neuroanatomy. The best diagnostic test, he said, were "pain patterns related to neuroanatomy."
Dr. Bogduk sounded like Cuba Gooding Jr. in Jerry McGuire: "Show me the money." Bogduk, on the other hand, was screaming to the Americans, "Show me the data." You see, he has a reckless disregard for our research. He did his best at insulting every one of our professional specialties that evaluate and treat pain. I might say he did this with class, and vigor.
The basis of his arguments were valid and hard to dispute, because his life's work is centered around scientific approaches to validating medical treatment approaches. He aggressively spoke out to the audience, "Show me the data." At this point, his attention was directed to manipulative specialists, mainly chiropractors. He stated that although there appears to be anecdotal evidence, there is no hard science behind chiropractic. He stated there are as many metanalysis studies on manipulation as there is valid research articles, which validates how political an issue it is.
Before you jump to the database section of your brain and start rolling off your list of favorite articles that validate your chiropractic paradigm, you need to know the criteria he aspires to. He talked briefly about two-by-two square analysis, kappa values, chi square tests, and Fisher exact tests. These are just a few of the procedural and statistical methods he requires that we use before we tout our outcome successes.
He stated that if you are at a conference and the speaker did not comply with these basic standards, you should call him a fake and walk out. He also said because the American research system is based on financial incentives, we all attended a theological college. He stated that the problem with chiropractic is that there is little examiner reliability. This means that the chance that two chiropractors examining the same patient will come up with the same diagnosis is poor.
I reminded him that this was done and published by Marsland, and Dr. Bogduk himself. He said that the study I referenced, where a therapist accurately predicted the symptomatic cervical facet joint that would respond to therapeutic blocks, was a fluke. He said they tried four other therapists with the same training and they all failed miserably. He concluded that the one therapist that did predict 10 out of 10 patients accurately was an aberration of her species.
I asked him about the training of the four therapists that failed, and he said that they had the exact training as the successful one; they were Maitland certified manipulative specialists. The only other time I had heard of Maitland manipulative procedures other than in articles was by a Dr. Banister, MD, a famous European orthopedic surgeon. He stated at a conference that he witnessed Maitland manipulative procedures and said he would rather be hanged by a rope, because it would only happen once and would be quicker.
I conceded to Bogduk that manipulation does have a varied skill level among practitioners but that I felt his sample base was flawed. I explained that the chiropractor is the best professional to evaluate the abilities or inabilities of manipulation. I explained that although our profession is the king of diversity, we do have subgroups that specialize in certain techniques. I explained we could evaluate the reliability, reproducibility, sensitivity, and specificity of one technique compared to another, and only use trained experts for each one.
He applauded the idea and then promptly told me that I could never get the "powers to be" to agree to such a study because someone would "lose." He said the American system is set up to ensure no one loses because it kills a donation or income center. If technique A was proven to be 75% more effective, reliable and reproducible than technique B, it would kill off a technique. If this pattern were to continue, only the best technique for any given diagnostic related group would survive. This would lead to a dreadful concept of patients getting the best diagnostic and therapeutic options for their condition, which would reduce cost.
Ahh, there's the problem! Reduced cost means reduced profits. The American system of capitalism is centered around this ugly word profit. It would drive several procedures, subgroups, techniques, and physicians out of business because their procedures or skills would be proven inferior. I told Bogduk if anyone could understand the plagues of politics, it would be our profession. I have read several horror stories about valid, effective treatments that were politically suppressed because they would destroy another more powerful treatment that makes "too much money." His contention is that the system is overloaded by its rich history of fraudulent and ineffective treatments, so it will correct itself in the near future. He contends that it will not matter what discipline you are; if it works the best, it will survive and the patient volume will follow.
I have always told my patients that just because they came to my office does not mean that they need my treatment. I have an understanding of other professionals' skills and acumen and attempt to get each patient to the best physician for their given diagnosis. This may even be another chiropractor. We need to learn to do more intradisciplinary referral. The underlying theme of my conversations with this man who should go into some physicians hall of fame somewhere are as follows:
We need to identify what diagnostic related groups we can treat with speed, efficiency, and grace, and fight hard to be the best. This will lead to an increased patient volume and exposure to our abilities. If these patients then want to pursue optimum health, and continued chiropractic treatment, they can do it with an agreement between you and them on a cash basis.
If we are to be competitive, the first step is to be realistic on who is the responsible party for our patients' spinal health. What have your patients done for their spines lately other than have you treat them? If they are not contributing to the recovery or stability cycle, who should pay for the care they need?
Will your office change to prepare for the new competitive third- party system, or will we again let a golden opportunity pass us by in the name of philosophy? I have scanned the globe for the best techniques available to treat pain patients. I have found several of them existed in our own office; we just need to learn how to apply them more appropriately.
I encourage you to go back and relearn your neuroanatomy, as this is the template for diagnosis. There are several excellent soft tissue and treatment techniques, but the best guide for treatment is the little person in your stomach telling you if you have an exact answer for your patient's complaints that validates your treatment. Successful treatment is the hallmark of an accurate diagnosis, and this occurs quickly if applied properly. Results will be the ticket for our professional advancement.
I have witnessed first hand the power of medical affiliations. Our practice flourished because we understand the medical referral model. These individuals are not "the dark side." They have the same compassionate goals that we do for their patients. They are willing to work with our profession provided they get one thing: a predictable and acceptable working relationship (they do not want the referral to make them look bad). They control the key to our professional momentum, because if we can show them which diagnostic related groups we treat better than anyone else, and they refer them to us, we improve their profile statistics. They need their outcomes to look good, and they don't care who helps them.
In this day and age they have to stay competitive. This is the oldest method of practice development and marketing alive, the "back scratch." I advise you to explore the vistas available to your offices by interacting with the other 85% of the population that our profession has restricted itself from for over 100 years.
Scott Rosenquist, DC
Colorado Springs, Colorado
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