To: Editor, Medical Economics
Re: "Take It from a DC: A Lot of Chiropractic Is a Sham,"
authored by Mark Sanders, D.C.
Dear Editor,
We are particularly concerned about the deception of the norms of chiropractic practice with regard to diagnosis and appropriate referral. I have attached for your reference this association's official policy statements on these matters. I invite you, as well, to examine the standards of the Council on Chiropractic Education (CCE), the federally recognized body that accredits the chiropractic colleges attended by 98 percent of chiropractic students in the United States. Examine also the faculty qualifications and study programs of the CCE accredited institutions with regard to diagnostic training. You will certainly see that systematic diagnosis is an integral part of chiropractic education.
In clinical practice, diagnosis is appropriately applied by the vast majority of practitioners, in the vast majority of cases. The records of state licensing and disciplinary boards show the relative rarity of the need for actions against chiropractic licenses for misdiagnosis. Likewise, malpractice actions in this regard are, on a per unit of care delivered basis, relatively rare.
It is clear to us that Dr. Sanders, in his relatively isolated position, is either unaware of or is intentionally misrepresenting the norms of chiropractic practice. We are seriously and legitimately concerned with the means by which he attempts to validate his assertions. The employment of undocumented case stories to parade the imaginary horribles of what can happen is so far below the accepted standards of scientific validation as to be laughable.
I wish to make specific reference to a passage in the draft article, page 7, line 40c-40g, which states: "It's not unusual for a chiropractor to recommend 100 manipulations for a simple back strain." I would challenge Dr. Sanders to validate this assertion with verifiable documentation. You must be aware that doctors of chiropractic practice under the same economic and utilization constraints as do other licensed primary providers. There is not an insurance company, peer review board, state disciplinary board, Medicare utilization review specialist, national or state chiropractic association that would deem such a program of care as appropriate. Likewise, I am confident that this same lust of authorities would challenge the assertion that the 100 manipulation prescription is in any way common.
We hold the position that maximum cooperation and understanding between health professionals is in the best interest of the individual patient and of the American health care system as a whole. It is impossible for us to see how the proposed article can contribute to this goal. Furthermore, in its present form, the publication of Dr. Sanders' article could serve to discredit your publication, and draw legitimate criticism of the process which led its printing.
Ronald M. Hendrickson
Executive Vice President
International Chiropractors Association
Dear Mr. Berg:
"The protrayal of the chiropractic profession, as well as the interaction between medical and chiropractic doctors, is neither accurate nor factual. Short of offering a titillating headline that is guaranteed to anger one health care group - - chiropractic, and frighten another -- medicine, little is offered that contributes to the public's understanding of several critical issues.
"So what is an appropriate course of action now, following all this innuendo and anecdotal reference? First and foremost is the need for an accurate understanding of the status of chiropractic standards of care, a notion on which Dr. Sanders places enormous weight in his presentation and about which he is seemingly incredibly unknowing.
"Secondly, many recognize the chiropractic profession is making incredible headway in the area of efficacy, the second of two points on which Dr. Sanders seems to shape his presentation.
Efficacy
"The recent report from the British Medical Journal titled "Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment" is a superb example of efficacy. The study concludes, among other things, that consideration should be given to the inclusion of chiropractic care in the British National Health System.
"Granted, more studies on efficacy are needed. The American Chiropractic Association and its members favor a much more extensive investigation; we eagerly await each pending study and its potential to further validate chiropractic.
Standards of Care
"For some time now the American Chiropractic Association, in close coordination with other chiropractic health care organizations, has sought to address the issue of standards of care (the second point on which Dr. Sanders rests so much of his case). Dr. Sanders seems to base so much of his argument on standards of care, it is incredible to note he is not informed as to the status of one of the most profound developments within his profession.
"In any case, this ongoing multimillion dollar commitment to establish standards of care on behalf of the nation's chiropractors is being conducted by RAND Corporation.
"Quite frankly, many have asked that I respond by debating the individual points raised by Sanders. I couldn't in good conscience attempt to do so. I don't accept the very terms for debate the good doctor has offered. They are so outdated it would be like debating the roundness versus the flatness of the Earth."
David R. Shingler
Director of Communications
American Chiropractic Association
Dear Mr. Holoweiko:
"In an opinion piece recently published in Medical Economics, Mark Sanders, D.C., described much of chiropractic care as "a sham" and stated doctors of chiropractic need to document the efficacy of chiropractic and to standardize services. We beg to differ with this view, which has been heard before.
"The efficacy of chiropractic care is documented in the June 1990 issue of the British Medical Journal. The Medical Research Council of Britain funded a two-year study of chiropractic care that was conducted by the National Health Service physicians. The results determined that chiropractic treatment is more effective than hospital outpatient management, mainly for patients with chronic or severe back pain. After this extensive two-year study, the Medical Research Council recommended that England's National Health Service begin including chiropractic care.
"In Dr. Sanders' opinion, "Chiropractic therapy tends to parallel the normal course of untreated back pain." Yet, scientific studies demonstrate that spinal manipulation can accelerate the resolution of back pain. The March 1989 issue of the Western Journal of Medicine, published by the California Medical Association, contains results of a 1989 study, indicating chiropractic patients make quicker recoveries than those treated by traditional medicine. The study was conducted by Daniel C. Cherkin, Ph.D., and Frederick MacCornack, Ph.D. The two researchers compared health maintenance organization enrollees' evaluations of the care they received from family physicians and doctors of chiropractic. Low back pain patients of medical doctors averaged 39.7 days of restriction from normal activities during the eight-month study period while chiropractic patients needed an average of only 10.8 days. Additionally, 83 percent of those seeking treatment from doctors of chiropractic experienced less than one week of restricted activity, while 52 percent of patients treated by medical doctors were restricted for the same amount of time.
"At its May meeting, the California Chiropractic Association (CCA) board of directors reinforced its commitment to the highest level of health care ethics and released a strong position against unethical practice management firms. The board of directors formed a Practice Management Committee and issued four standards in its two-page position paper. The four standards are:
"No student should be signed to a practice management agreement until after graduation from a chiropractic college.
"Practice management contracts should be on a fee-for-service basis rather than on a percentage basis, in addition to being cancelable on short notice.
"No practice management company should ever advise or teach any doctor to say or do anything that is not completely honest, ethical, legal, and truthful.
"Practice management companies should not engage in any self-dealing, such as advising doctors to purchase or lease equipment and services from companies owned or affiliated with the practice management firm.
"Chiropractic care is the second largest healing art in the world. Chiropractic care emphasizes wellness and is a drug-free, non-surgical approach to health care. It is unfortunate that Medical Economics chose to publish Dr. Sanders' narrow and jaded opinion of chiropractic care. If I can be of further assistance, please do not hesitate to contact me or the CCA Public Affairs staff."
Willard B. Smith, D.C.
President
California Chiropractic Association
"As I read with utter revulsion the article by Mark Sanders, D.C., Take It from a DC: A Lot of Chiropractic Is a Sham, it seems evident that the late Robert S. Mendelsohn, M.D. (Confessions of a Medical Heretic) is indeed alive and well. But this time the "shaman" wears the white coat of the chiropractor. Both authors are an embarrassment to their respective professions. Would you not agree that neither painted an accurate picture of either profession?
"The mainstream chiropractic physician today does not practice in any way as depicted by Dr. Sanders. My profession would not be in existence since 1895 if our forte was directed at duping patients, as this article implies.
"Please do continue to investigate the chiropractic profession with an open mind; you will be pleasantly surprised."
C.J. Jungblut, D.C.
Holland, Michigan
"The entire chiropractic profession should read the embarrassing article and then there should be a professional reprimand against Dr. Mark Sanders.
"The article sounds more like it was written by a medical author with a distorted view of chiropractic philosophy.
"Why do I get the feeling that Dr. Sanders would rather have an M.D. behind his name instead of D.C.? Do you suppose he may have a pseudomedic ego problem?
"Apparently he took it upon himself to be quoted in the magazine and air our dirty chiropractic laundry before the rest of the medical community for their enjoyment.
"Our greatest threat lies from within our own ranks. ... Many times we are our own worst enemy ... and Dr. Sanders is a shining example."
Name withheld at author's request.
Dear Mr. Berg:
"It is difficult to know how to respond in an appropriate, professional manner to comments made by Dr. Mark Sanders, in the September 17, 1990 issue of Medical Economics. The difficulty is two-fold: First, because many of the criticisms Dr. Sanders levels at the chiropractic profession are justified and painful to acknowledge; second, because he takes aim at several aspects of chiropractic which are not deserving of his capricious condemnation.
"It is particularly painful to acknowledge the profession's past failure to conduct adequate research to validate its theories, but this is beginning to change ... through the efforts of such organizations as the Foundation for Chiropractic Education and Research (FCER), the National Institute of Chiropractic Research (NICR), and the Consortium for Chiropractic Research (CCR) -- some "catch-up" research is under way.
"Consequently, during the past six or seven years, considerable effort has been given to conduct various forms of studies relating to this procedure which has been documented for critical assessment in peer-reviewed journals and published conference proceedings. However, it appears that Dr. Sanders is either not keeping up with his profession's research activities, or he is deliberately distorting the facts to serve his own purpose. If the former is true, he is unqualified to make "informed" judgements on the present-day status of any of the procedures he used as "sham examples" in his article or, for that matter, the profession as a whole. If the latter is true, his professional ethics, at the least, are seriously in question."
Arlan W. Fuhr, D.C.
President
Activator Methods, Inc.
Dr. Fuhr supported his letter with various research articles in chiropractic publications. -- ed.
Dear Editor:
"The first three paragraphs are well written and insightful. I, too, think MDs need to know to whom they refer patients. It is also as important to know the MD to whom chiropractic patients are being referred. This is only good practice management and care for the patient and his condition as well as his protection for his professional opinion.
"Dr. Sanders, I do not know at what chiropractic college you taught. Nor do I know what you taught or why you left the academic arena. I have also been doing utilization reviews and have found gross negligence as you described. However, you seem to negate the overwhelming number reviewed are the same ones that habitually try to beat the system with unwarranted tests, charges that are not commensurate with the treatment, and/or diagnosis, unnecessary therapies, and adjunctive supports without documentations to the necessity of such. Believe it or not, Dr. Sanders, the medical profession have theirs, they just do not write articles about it in the chiropractic journals.
Questions:
Harold B. Tondera, D.C., F.A.C.O.
Houston, Texas
Dear Dr. Sanders:
After reading your article in the September 17, 1990 issue of Medical Economics "Take It from a DC: A Lot of Chiropractic Is a Sham," I have taken the time to let your thoughts settle in before telling you some of mine.
I now feel my opinion of your behavior has at least somewhat solidified.
I read an editorial many years ago which talked about how a black reporter would be castigated if he utilized black stereotyping in any of his articles; he would not last long. The editorial went on to discuss how a Jewish reporter would find he had a short career if he wrote about the stereotypical image of the Jews. But, if an Irishman wrote that the Irish were "knitters of sweaters and singers of songs" no one would say much about this. The reason for the lack of reaction when it comes to an Irishman -- even though the Irish have been very progressive and in fact arguably have climbed to the top of the economic heap in America and elsewhere -- is that Ireland has been under English rule for over a thousand years. During this time Britain has held a very low opinion of these particular subjects (Irish). The Irish, thus subjugated for a millennium had finally taken on the same low opinion of themselves held by the occupying power. They, therefore, can hear themselves characterized in derogating terms without thinking much of it.
I suspect that you have now yielded completely to the attitudes of the "occupying power," i.e., the American Medical Association. The AMA has so destroyed chiropractors' and chiropractic's reputation through the many years of its viciously illegal boycott (and before), and has so lowered the self-esteem of the profession that certain ones among us have finally bought the stereotype; I believe one of these is you, as represented by your article.
I have often said that medicine is not as good as its image (Marcus Welby, etc.), dentistry is not as good as its image, but chiropractic is better than its image. After all, hasn't our image significantly been set by others, with the power to influence society's health attitudes?
You have made a good many, very qualified doctors of chiropractic angry and hurt with your sweeping characterization of them. Whatever good there was to say about aspects of your article must be lost in the swollen ego from which its author appears to be suffering. The arrogance between almost every line of the article seems monumental. The style of the article seems highly corrupted.
I am one who does agree that we should be speaking out against certain problems within our profession. It is still true that when such problems are highlighted, we must plan to root them out by ourselves. It is unfortunately the case that in other professions, unlike with us, when a problem is identified, society tends to come together to assist that profession in correcting those problems. We have been pretty much alone with our problems, sometimes attempting to remain afloat through the use of "life preservers" (such as certain practice management procedures, certain therapies, etc.) which were frequently associated with unethical or aberrant behavior. But I also believe that our speaking out should be of the type that will assist the profession rather than harm it. Your article smacks of a father breaking a daughter's leg for coming home late after school. I hardly think this was necessary.
I had an occasion many years ago to speak to the chairman of the Sports Medicine Committee of the U.S. Olympic Committee. He asked me a question as to whether chiropractors generally had something to do with the manipulation of the spine and other musculoskeletal articulations. My answer was in the affirmative. He said he had talked to one particular chiropractor who did not seem to be able to answer this question. He had asked the DC who he (the DC) thought might be one or two good chiropractors to appoint to a subcommittee on Alternative Health Care Methods of the Sports Medicine Committee. The DC answered, "I am the only chiropractor that could handle such a task. I am the only one who knows enough about this area of health care." This type of arrogance usually prevents the individual, I have found, from being aware of how really foolish what he is saying actually is. It shows a narrowness of vision that hides great ignorance outside the confines of the vision. Such a person can easily be trapped or almost blindly led into self-destruction and the destruction of those around him. This, of course, is an individual's right and no one can deny him that right. It is sad, however, that in such an action the individual can harm many good and caring people along the way. Cynicism may also be blinding him.
The National College of Chiropractic is even now leading an effort to develop solid data for the chiropractic profession, data that neither it nor you have had available to be able to make the somewhat inflexible statements about the efficacy or lack of efficacy of particular methods of therapy utilized by our profession as you have made. I hope you and others like you will find it more expedient and self-aggrandizing (since this is clearly part of your motivation) to assist in accumulating such data and in the process use less of your time in lashing out against others. It would certainly seem the professional thing to do.
Jerome F. McAndrews, D.C.
Assistant to the President
National College of Chiropractic
Lombard, Illinois
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