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"A Veiled Attempt to Call Attention Away From Actual Problems"

Dear Editor:

Upon reading the article regarding the suit filed against the Texas Board of Chiropractic Examiners over scope of practice [see "Texas Arm of the AMA Strikes Out at Chiropractic, Oct. 26, 2006 issue], the need to offer comment was more than compelling - although it is first important to provide some background.

The "doctrine of reasonable prudence" (affirmed by Judge Learned Hand in the T.J. Hooper decision, 1932) plays a very crucial role in the daily practice of medicine, especially when relating to issues concerning standards of care. By the standard of "reasonable prudence," when one considers the overall risk of spinal manipulation, which is technically statistically insignificant, compared to the potential for clinical benefit, once could justifiably argue that every patient with neck or back pain should be assessed for the potential benefit of spinal manipulation. In this regard, there is a potential argument that not considering manipulation as a treatment intervention could be considered negligent by omission. This argument is still viable even if the potential for benefit were not as favorable as it actually is, since the risk is quite small.

Most individuals are unaware that the evidence supporting the clinical use of manipulation dates back before B.J. Palmer or even Andrew Still. When reading the work of Hippocrates, On the Articulations, translated by Adams F. London in 1849, it is clear that manipulation as we know it dates back to the father of modern medicine himself. Hippocrates even created devices to help facilitate treatment, technically the first manipulation tables and traction devices.

Consider for the moment that Darwinian Theory applies to medical procedures and devices just as to evolution. Treatments, including those labeled as snake oils, come and go with time. Yet in the 2,500 years since Hippocrates, manipulation remains a mainstream treatment for musculoskeletal conditions related to the spine. This persists not as result of double blinded clinical trails, but through actual clinical outcomes, overall patient satisfaction, and the very negligible incidence of adverse events. If there truly were a practical absence of clinical outcomes and a tendency for treatment to result in adverse events, manipulation would have fallen out of favor as a treatment through evolution quite some time ago.

Incidentally, manipulation dates back even another 2,000 years or so (that would be a 4,500-year history of manipulation, if you are keeping track), to one of the oldest known medical documents, the Edwin Smith Papyrus. This is a copy of an ancient composite manuscript which contained, in addition to the original author's text (3,000-2,500 B.C.); a commentary added a few hundred years later in the form of 69 explanatory notes (glosses). It contains 48 systematically arranged case histories, beginning with head injuries, extending caudally through the spine before breaking off at the end. These cases appear generic and commonplace rather than actual case reports. Each presentation is divided into title, examination, diagnosis and treatment. Of the 48 cases described, 27 concern head trauma and six deal with spine trauma. The last case deals with back pain, providing the diagnosis of a "sprain of the vertebra." It describes a version of a straight-leg-raising test, as well as the treatment by "prostration." Essentially, this is straightening of the patient through manipulation.

Over the past 4,500 years or so the number of patients who have experienced adverse outcomes from manipulation in published literature seems very limited in total. How does this number compare to the published data pertaining to medication errors, adverse effects associated with medications, iatrogenic illnesses or surgical complications?

While on the subject of surgery, have you taken the time to look up the definition of surgery in Stedman's Medical Dictionary lately? It is defined as "the branch of medicine concerned with the treatment of disease, injury and deformity through operation or manipulation." I believe reading the definition of surgery in one of Hippocrates' writings as being quite similar. According to Wikipedia, the term "surgery" has as its root form cheirourgia (Greek), meaning "hand work." Of course, surgery is the medical specialty that treats diseases or injuries by operative manual and instrumental treatment. Surgeons are medical practitioners who specialize in surgery. In this regard, by definition, all manipulation performed by chiropractic physicians would be considered surgery, and thus chiropractors would be considered very specialized surgeons.

The adverse effect of economics on the practice of medicine is one of the topics discussed quite often these days. Arguably, as a result of increased financial and time pressures, the average time of a consultation is decreasing. This can be especially seen in the field of primary care. In performing your own literature search, you will likely observe quite a consistent consensus in reporting that longer physician consultations may be associated with greater patient satisfaction, correlate with increased health education/prevention measures, and are linked to better clinical outcomes. This is why CMS is increasing fees for consultations for the upcoming year. Combined with the tendency for increased specialization that helps create more highly skilled, problem-specific craftsman (remember the theory here applies not just to health care), it would seem to make common sense that those with the highly honed skills in assessing and treating the disorders related to the spine be permitted not only to use their skill, but also to be sought out.

Remember, the primary care physician tends to involve the use of specialists to perform detailed problem-specific examinations and offer a carefully tailored treatment. If this skill requires the use of certain "tools of the trade" such as an EMG, and the craftsman is skilled in the use of the tool, what would be the rationale for not permitting its use? For that matter, if not for some other reason, common sense would suggest that a chiropractic physician would be a cooperative asset to those in primary care.

Turf wars do exist in the field of medicine, just as in most any other profession or business. It is not as if the practice of chiropractic physicians performing EMGs just started yesterday. Having personally performed electrodiagnostic studies in clinical practice for over 15 years, there is clearly a history that can be reviewed. Has there been any evidence of increased morbidly or mortality occurring as a result of such practices? Since the answer to this question is "no," common sense would dictate that the argument of protecting the public from health care providers who are not properly trained in this case would be a myth, since there does not appear to have been any evidence of harm.

The entire action would seem to be a veiled attempt to call attention away from actual problems within the health care system. If protecting the public and patient safety were really the primary concern, as was reported for this action, one would expect the parties concerned to focus on matters that actually do result in greater risk to the patient, not to mention increased financial burden to the health care system. Consider, for example, the recent study published in the Journal of the American Medical Association, reporting the findings from the Centers for Disease Control and Prevention. The researchers found that 2.5 percent of all ER visits and 6.7 percent of ER visits leading to hospitalization were due to adverse drug events. This would represent a total of 701,547 hospital emergency room visits and 117,318 hospital admissions each year as a result of adverse drug reactions. Given the actual impact on the residents of Texas, one would expect the time and resources of the Texas Medical Association could be better focused on addressing potential problems resulting from the direct actions of its members.

Lastly is the subject of diagnosis. By definition, diagnosis refers to the process of identifying a medical condition or disease by its signs, symptoms and clinical examination. A medical condition is defined as an abnormal condition of the body or mind that causes discomfort, dysfunction, or distress to a person. Even when considering something as seemingly simple as back pain, which is a symptom, one would have to essentially diagnosis the cause of the condition in order to provide a means of correcting the problem.

Chiropractic physicians do not just haphazardly provide random manipulation of the spine. They exercise a carefully constructed method of diagnosing the underlying problem so as to determine the most effective means of treating the same. In this regard, the term "medical" refers to the condition resulting in discomfort, distress and dysfunction, not the discipline of allopathy. And besides, even if it did, technically as a chiropractic physician, we are all surgeons, and who would argue that a surgeon would be prohibited from offering a medical diagnosis?

David M. Glick, DC
Richmond, Virginia