Guidelines for Evoked Potentials
Dear Dr. BenEliyahu:
Thank you for your insightful and informative articles regarding SEPs. I'd like to get the "Guidelines to Evoked Potentials" by the American Electroencephalographic Society. At your convenience, would you supply me with an address and/or phone number?
Jerry Marshall, DC
Locust Valley, New York
The address of the American Electroencephalographic Society:
One Regency Drive
P.O. Box 30
Bloomfield, CT 06002
Blind-Sided Dear Editor:
I have followed with great interest the publication of information on the Orthopractic Manipulation Society International (OMSI). Your reports have been most informative and I trust are not falling upon deaf ears within the profession.
My interest is as a 20-year patient of chiropractic, a 17-year teacher of chiropractic students (Canadian Memorial Chiropractic College), and as a lawyer who has participated in various legal issues involving chiropractors.
It is with anticipation and trepidation that I follow the development of orthopractic. I am not an optimist by nature, and am paranoid by training. There is a saying, "Just because you are paranoid does not mean that the world is not out to get you."
I have watched with deep interest the development of the chiropractic profession since 1975. To an outsider, the progress of the profession has been astronomical in almost every aspect of the profession: research, education, political stability, legislation, and interprofessional interaction. Has the profession become so complacent in its approach to the fact that it is the third largest primary health care provider that it has been blind-sided? I would suggest that this is exactly what has happened.
The only questions will be whether the profession goes down with a fight or merely a whimper, and secondly, who will be the author of the destruction?
Chiropractic has been successful in not only maintaining the ability to provide care to patients, but to increase the scope of practice, despite the protestations of the medical profession. However, we know something that anyone who has not received chiropractic care does not seem to appreciate, and that is that chiropractic works. Scientific research is important for the development of any health care profession, but the patient is interested in results.
What is it about "orthopractic" that causes me to be so paranoid? It is simply that chiropractors cannot argue against the position of orthopractic if members of the chiropractic profession, who might otherwise be respected members of the profession, support the position of orthopractic and join in advancing its positions. There may be 30,000 chiropractors who take exception to the position of the orthopractors, but the vocal minority will scream loud enough to ensure that the public takes a long hard look at the debate.
The first consideration by the public will be who is doing the talking. In the case of chiropractic and its associated problems it is usually the medical profession. It has been some time since the media joined in the eating frenzy. Now we have both groups together with physiotherapists and unfortunately chiropractors are expounding the limitations which should be placed upon chiropractic.
The second consideration by the public will be whether there is a more cost effective treatment which can be provided.
Lastly, the public will consider who should provide the care that is being suggested. Since the orthopractors have developed a "code of ethics," and are able to refer a patient to a practitioner who abides by such a code, it is not likely that patients will soon be investigating what alternative practitioners are available.
All of the above comments do not yet even deal with the sleeping giant -- that being the groups who pay for chiropractic care, i.e., government and insurance companies. While the scope of chiropractic has been entrenched in legislation after years of debate, it should be remembered that the practice of chiropractic is a privilege and not a right (at least in Canada, if not the U.S.). It is a privilege that has been given and can be taken away. To appreciate this fact, I would suggest that anyone can examine the practices of osteopathy and podiatry in the province of Ontario.
We now have chiropractors agreeing with the philosophy, policy, and principles of orthopractic. The principles expound such matters as no chiropractic treatment for persons under the age of 18 (as if 18 is some magic number); no x-rays for spinal adjustment (subject to various exceptions and even then the x-rays are to be referred out). What I did not notice was even an iota of proof of competency in the ability to provide such care by medical doctors, physiotherapists, etc.
The chiropractors who join such an organization should consider a number of issues. First, why is it that an outside organization should be in a position to dictate what an acceptable determination of chiropractic treatment scope and patient qualification? Is it that the "truth" has finally been found by the OMSI notwithstanding that the ACA, ICA, and CCA have spent years and countless funds to participate in research, reviews, and studies to advance the science of chiropractic and have ultimately created the standards of the profession?
The province of Ontario the last 14 years has been participating in a legislative review involving all of the health professions in determining scopes of practice, patient care and self-governance to the point where countless millions and millions of dollars have been spent. Is it that governments, such as Ontario, are incorrect in maintaining and even advancing the position of chiropractic? Does the OMSI know something that the review did not know? I would suggest not, and I would suggest that any chiropractors who involve themselves in orthopractic should take a long hard look at what they have done. If there is a need for change, it should be done from within.
What is going to happen next. Is your profession going to be told that treating pregnant women is inappropriate? After that, why not stop treating geriatrics? Why stop with those two groups? Why not stop x-raying by chiropractors? Why not prohibit treatment of any group whose care might also include medical attention? In fact, why not just allow treatment of chiropractic patients after it has been determined that such care has been found to be satisfactory by a medical doctor? This sounds familiar. Just speak to physiotherapists. I suppose this could create a new adage in the attitude between physiotherapists and chiropractors: "If you can't beat them, have them join you."
Mark my words: If the associations do not take immediate steps to remove any relationship between themselves and chiropractors who join orthopractic, the profession is doomed. The creators of orthopractic are not going to go away. The sales pitch to the medical profession is too good. The media appears to be in love with the approach of the OMSI. The public will soon catch on. The governments will not be too far behind.
The profession must deal with the matter as a fight to the finish. There is no purpose in avoiding the argument with orthopractors and in particular the chiropractors who support them. The battle lines are drawn and the winner will take all!
Allan M. Freedman, attorney
Toronto, Canada
"Let's at least understand their language"
Dear Editor:
Every chiropractor is concerned over the much debated managed care. Unless this profession can bend and flex to make compromises for the benefit of all, we stand nothing to gain.
At this point, all those who wish to fulfill the role as the primary gatekeeper can forget it. Why? Well, the federal government might reply with something like this: "Since chiropractic practitioners are not generally authorized to prescribe or administer controlled substances, their knowledge and training does not include this specialized area of pharmacology." The basic concept has been effectively used against our profession by several departments of the federal government. (See the Department of Health and Human Services guidelines for workplace testing programs [April 1988] and see the US Department of Transportation testing procedure regulations, 49 CFR Part 40). If you need proof of this I will send it to you upon your request.
You can bet the federal government will define the "primary gatekeeper." Again they will define this individual as "someone who needs to have specific knowledge in the pharmacology of controlled substances including the legitimate medical use of such substances and its abuse." It would stand to reason again for the federal government to state that chiropractors are not best suited for this role since they lack pharmacology knowledge and therefore, are unable to determine (diagnose) if an individual needed to be referred to the medical profession for medication or not.
To teach or not to teach "pharmacology" in the chiropractic curriculum? I don't think that this is an issue any more. This must be taught in an official academic environment to receive federal recognition or acceptance. Teach this purely for the "knowledge" and not for the means to gain the right to prescribe medication. This "knowledge" will serve you on many platforms; all federal programs will no longer be able to discriminate against us upon that basis. Patients will benefit. You might be able to possibly save someone's life. Is that worth it? Let the chiropractic profession remain a non-drug profession, unable to prescribe medication. Let's at least understand their language. It is imperative that the scope of practice of chiropractic physicians include a knowledge pharmacology. I have not seen any state statute that would conflict with chiropractors acquiring pharmacological knowledge. The education in pharmacology would give our hard working ACA representatives more ammunition to defend us from government bias. Why does not CCE stay current with the demands of future trends and needs?
Richard T. Pfaff, DC
Lakeland, Florida
An Open Letter to Dr. Murray Katz Dear Dr. Katz:
For the last year or more I have watched with curiosity your campaign for "scientific" chiropractic and your support of the orthopractic practice. In many ways I agreed with you on the current status of some chiropractic practitioners and their "practice methods." I have always been a person who believes that another person has the right to speak out when they feel a wrong needs to be righted, even if I do not agree with the viewpoint. I have always felt that there is a need for "scientific proof" of what we as chiropractors do. I also believe that even though this "proof" has not yet been found (or explained through our schools) that is does exist, and has not yet been discovered. The physiologic and mechanical changes that take place during chiropractic treatment make changes that we have yet no way of recording or even properly evaluating. The art of applying chiropractic adjustments also creates a factor that most likely is the reason this cannot be discovered in a laboratory.
I have read your writings in both Dynamic Chiropractic and other publications in which you have been quoted, and have until this time, felt that your concern was for the well being of the public. However, the most recent article in Dynamic Chiropractic in which you state that you feel there is no need for chiropractic care in children, finally reveals what your purpose was all along. You want to retain the rights to treat children within the allopathic field and that alone. This is very clear by your statements. It is fortunate for you that you practice in Canada, as we have already won a restraint of trade suit against the AMA for just this type of action.
It is of great interest to me that the chiropractic profession has been treating children for almost 100 years, and now you seem to be interested in our actions. Could this be because we used to treat children for free and now we have begun to charge for our service? Show me statistics that compare chiropractic care to medical care and the damage done per 100,000 by both and then we can determine which care is the safest. It is now very apparent that the only thing you are trying to protect is your pocketbook and that of other allopathic pediatricians.
Kenneth E. Martin, DC
Temple City, California
"I will argue with his viewpoint on clinical excellence."
Dear Editor:
I was gratified to see the recent review of Topics in Clinical Chiropractic by Keith Innes, DC. I thank him for his objective examination and appreciate the critique he offered. Each issue involves a tremendous amount of work on the part of the entire editorial staff, with one of the editors taking primary responsibility for coordinating authors and manuscript preparation on a given topic. As a new journal with a unique approach to addressing issues we believe to be relevant to practicing chiropractors. We have and will continue to undergo much growth. His review raised a few points that warrant comment and clarification.
The appendixes section of every issue contains clinical aids including forms, algorithms, directories, checklists, and other items we hope will be of value to our subscribers. While we encourage authors to draft clinical algorithms and other practice aids to go with their manuscripts, some articles may not lend themselves to an appendix, and some clinical subjects may not have enough basis to write a good algorithm. The art and science of writing clinical guidelines, algorithms, and care pathways is still young and quite challenging. Dr. Dan Hansen has served as a great resource to me and our authors in writing, editing, and revising TICC's clinical algorithms.
In Dr. Innes' review he wondered if these forms and algorithms could be reproduced for clinical use by the reader. The first page of the Appendixes section does give the reader permission to copy and use these items within his or her personal practice, but does not permit reproduction or distribution for resale. Dr. Innes should also be happy to know that "Clinical Pearls," edited by Dr. Linda Bowers, will be an ongoing regular feature of TICC. Dr. Bowers welcomes comments and submissions from readers.
Lastly, Dr. Innes challenged a few minor, yet significant points raised in some of the articles in the second issue. While I won't attempt to debate the author's intent or Dr. Innes' viewpoint on the specifics in this forum, I will argue with his viewpoint on clinical excellence. I believe his comments in this area crossed over the line between a "journal review" and "letter to the editor." My complaint here is a selfish one, in that I would have loved to published his comments with a response from the authors in the "Letters to the Editor" of TICC. But that cannot happen now. It is my contention that clinicians are exposed to conflicting findings on patients, differing viewpoints in the literature, contradicting theories, inconsistent facts, and biologic variability on a daily basis. There are important characteristics of clinical excellence that go way beyond being current with the latest opinions or findings in clinical science such as biomechanics. Having the ability to critically appraise and synthesize the volumes of contradictory data the practitioner might be exposed to in the course of being a doctor is also an important component of clinical excellence. I have yet to come across a journal or text, whether it promotes clinical excellence or not, that is not subject to such variability, and at time inaccuracies.
As was stated in the first issue: "We welcome scholarly and clinical discourse about material presented in TICC ..." One of my favorite features of any publication is the letters to the editor. It is my hope that this section will become one of TICC's best liked features, with readers taking issue with authors and vice versa. This is the forum in which scholarly literature deals with differing viewpoints, improper conclusions, and factual inaccuracies that exist in the clinical domain. It is here that the readers witness critical appraisal and synthesis that occurs on the pathway to excellence. TICC does not claim to be the final word on clinical excellence. However, I do believe it to be perhaps the finest vehicle of its type that the profession has to pursue it.
Robert D. Mootz, DC, DABCO, FICC
Editor, Topics in Clinical Chiropractic
