Don't Discount Clinical and Observational Evidence
Dear Editor:
This is a response to Dr. Perle's article on "Ethical Analysis of Vertebral Subluxation Based Chiropractic" [Dec. 16, 2004 issue]. Although Dr. Perle's article was an interesting intellectual exercise, he fails to acknowledge that there is very little done in health care that does not violate the duty of nonmalfeasance or fidelity. Good or bad, that is the nature of working with living beings that cannot be dismantled and reassembled like a machine.
How many drugs are prescribed to treat conditions for which there is no evidence of efficacy or safety? How many discs are operated on just because there is pain and a positive MRI finding? How many prescriptions of antibiotics are written without definitive evidence of bacterial infection? How many arthroscopic knee debridement procedures are still performed after the only study showed that this procedure was no better than placebo? The medical profession is much more flush with these ethical violations than chiropractic, especially when you consider the risk-to-benefit ratio. If anecdotal evidence is not sufficient to justify chiropractic care, why is it sufficient to condemn it?
Where are the conclusive studies that chiropractic care caused stroke, disc herniation, cauda equina syndrome or rib fractures? There are none. Does that mean that these events are never the sequelae of chiropractic care? No, but it does mean there is a paucity of objective evidence to support that they do. The same rules of evidence should be applied to both the risk and the benefit as to other health care professions.
I am quite comfortable with the observational evidence that I have acquired over the years, that the service that I provide my patients provides great benefit in most cases and certainly justifies my clinical recommendations. I use this same evidence to determine when a patient might not be suitable for my care and to determine when a particular type of adjustment might not be appropriate.
There is no question that these issues need to be addressed, but there will not come a time during at least the next generation or two where appropriate and necessary health care can be provided without relying on clinical experience and observation in place of controlled scientific study.
Greg Baker, DC
Chatsworth, Georgia
"Taking Responsibility for Too Wide a Range of Disorders"
Dear Editor:
This is regarding Dr. Lavitan's review of Dr. Brown's Physical Diagnosis for the Chiropractor in the 12-16-04 issue of Dynamic Chiropractic. I am perturbed about the assessment techniques described, specifically the comparison of the examiner's vision and distal phalangeal sensory capacity with those of the patient. I would like to hear from Dr. Brown about how inter- and intra-examiner reliability is addressed when using these procedures. Is there a correction factor to be applied for the examiner's possible defects? As for the cardiac issue, I am interested in the studies that support measurement of respiratory and pulse rates by a DC as being superior to medical cardiology evaluation.
In the real world, all primary care doctors screen for conditions requiring referral; in these cases, an opthalmologist, neurologist and cardiologist would likely be consulted. Any responsible DC who was properly trained in differential diagnosis does this already, while continuing to treat if appropriate. The finger-rubbing test for hearing is no revelation and I fail to understand how restoration of a patient's hearing with an adjustment, as great as that may be, demonstrates its effectiveness. I suppose the Harvey Lillard parallel in the reporting of this particular single-case "study" would be by pure accident. I'm not opposing a wider range of DC education about non-NMS disorders, because we can surely help, but in a complementary, not a replacement mode. We've done this for over 100 years already, that's why not even the gargantuan medical industry has been able to get rid of us, because of patients' needs. But taking responsibility for too wide a range of disorders without verifiable specialization in those areas is just not defensible; mastery of the biomechanical/neurological nonsurgical option, i.e., the adjustment and other services that we are licensed to perform within scope, is. And we do have credentialed diplomates within our own profession to refer to as well. If a DC is uncomfortable with differential diagnosis, the diplomate would likely take care of it.
Has Parker College considered the potential malpractice exposure their future DCs will place themselves in by taking responsibility for E & M of these non-NMS conditions? I'm not saying that chiropractic care can't help these patients, but I believe it's foolish to try to present ourselves as jacks-of-all-trades rather than masters of one. I've built a healthy practice in which a significant number of referrals are from MDs. When they see this type of chiropractic material, and they do, it is very difficult to explain away. My observation is that the MDs have been more open to the chiropractic referral than ever, yet they are given pause by some of the material being published, including the "get rich quick without having to work hard" ads in Dynamic Chiropractic. It doesn't make sense when we are finally coming into our own via actual scientific research and are poised to capture our rightful share of the huge spine care market, especially in light of the recent pharmaceutical troubles.
I see that Dr. Lavitan has credentials in acupuncture, and I would surmise that "low-tech" assessment methods are not unfamiliar to him; however, my objection is to the title of Dr. Brown's book, Physical Diagnosis for the Chiropractor. Why not, Alternative Physical Diagnosis Methods, or something similar? I am not opposing dissemination of possibly valuable information, but when the word "chiropractor" appears in the title, then my DC degree is on the line as well as the author's. And it's not once, it's over and over again. No, I'm not a "medipractor," but I would prefer to educate others about the chiropractic principles using reasonable and available scientific evidence. In fact, I've rarely had an MD dispute them when properly explained.
Please, colleagues, no hate mail, and I still want Dynamic Chiropractic sent to me so I can see what you're accepting for publication and be ready for the fallout. Mr. Petersen, you don't have a DC degree to defend, although with your passion for the profession, you should certainly get one. Then maybe you would be more sensitive to the appropriateness of your publication's content.
Desi M. Menendez, DC
Smithtown, New York
