The Institute of Medicine: Committee on Use of CAM by the American Public

My Dear Colleagues:

I want to thank the Institute of Medicine (IOM) for two reasons: First, for inviting my testimony this afternoon, but especially for carrying what I believe is the unfulfilled work of both the National Center for Complementary and Alternative Medicine (NCCAM) and the White House Commission on Complementary and Alternative Medicine an essential step forward by calling us to the table today. I also want to offer my strongest assent and congratulations to the Institute for its most pertinent and insightful assessment of American health care - first, in its forthright reporting of medical errors in 1999;¹ second, for providing one of the most equitable definitions among the many offered for "primary care";² and third, for having published (two years ago) the most candid and uncompromising assessments of U.S. health care, Crossing the Quality Chasm: A New Health System for the 21st Century.³ This last publication courageously concluded that "the American health care system is in need of a fundamental change," especially because "what is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns."³

We now know that superficial makeovers will not suffice. The IOM indicated that entirely new patterns of thinking will be necessary to escape this dilemma. "Our present efforts," suggested Mark Chassin, "resemble a team of engineers trying to break the sound barrier by tinkering with a Model-T Ford. We need a new vehicle, or perhaps many new vehicles. The only unacceptable alternative is not to change."⁴

With these facts in mind, I come to you as the director of research of a nonprofit foundation that, in its 60-year history, has provided over $10 million for pilot projects and support for postgraduate study in areas pertaining to the theory and practice of chiropractic health care. I am both joyful and dismayed - joyful because, in terms of achieving chiropractic research goals from a scientific standpoint, I can only share with you the greatest satisfaction, if not outright wonder.

Until about 30 years ago, chiropractic research was considered in some quarters to be something of an oxymoron, "falsely conceived and rather clumsily executed...[with a text] ... that should never have been accepted, on a subject that should never have been chosen, by [those] who never have attempted it." A depiction of chiropractic researchers? No, a description of George Gershwin's now-immortal opera, "Porgy and Bess," by the music critic Virgil Thompson.

Despite the fact that chiropractic has existed as a formal profession worldwide for over a century, most of what we consider to be rigorous, systematic research in support of this form of health care has emerged only in the past two-and-a-half decades. In 1975, Murray Goldstein of the National Institute of Neurological Diseases and Stroke concluded that there was insufficient research to either support or refute chiropractic intervention for back pain and other musculoskeletal disorders.⁵ Nearly 30 years later, we now can review with great satisfaction how back pain management has been assessed by government agencies in the U.S.;⁶ Canada;⁷ Great Britain;⁸ Sweden;⁹ Denmark;¹⁰ Australia;¹¹ and New Zealand.¹² All of these reports are highly positive with respect to spinal manipulation. Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.

In the past 20 years, at least 73 randomized clinical trials involving spinal manipulation have made their appearance in the English literature. Even more amazing is the fact that the majority of these have been published in general medical and orthopedic journals. These trials address not only back pain, but also headache and neck pain, the extremities, and a surprising variety of nonmusculoskeletal conditions. When spinal manipulation is considered, the majority of these trials have shown positive outcomes, with the remainder yielding equivocal results. There are 43 trials addressing acute, subacute and chronic low back pain; 30 show that manipulation is more effective than control or comparison treatments, and the remaining 13 report no significant differences between treatment groups. None of these studies appears to have produced a negative outcome, and none indicates that manipulation is less effective than any comparison intervention.^13,14

Other major accomplishments include:

1. the appearance of a variety of favorable systematic literature reviews;^15-17


2. the establishment of the first federally funded chiropractic Center for Excellence at Palmer University by NIH's NCCAM in 1997;


3. the publication of the "Headache Report" by Duke University last year;¹⁸


4. the securing of over $10million in federal grants within the past decade, when in 1991, this accomplishment was considered to be unlikely;¹⁹


5. the establishment of chiropractic services within the military; and


6. the historic signing of Public Law 107-135 on Jan. 23 of this year, mandating the establishment of a permanent chiropractic health benefit within the Department of Veterans Affairs health care system.

Even more remarkable is the efficiency of chiropractic research. When compared to the NIH budget of nearly $20 billion, the $10 million investment in federal funds is substantially less than a tenth of 1 percent, which makes it less than a rounding error. Put another way, as a couple of wags have offered in the past, the federal government must believe in alternative medicine, because it has given chiropractic researchers homeopathic doses of money with which to work.

If you were to sum up my feelings about how far chiropractic research seems to have come, I'd have to resort to a pithy quotation from a baseball hero many of us grew up with: Yogi Berra. When asked while manager of the New York Yankees whether one of his star players exceeded his expectations during a banner season, Yogi's remark was, "I'd say he's done better than that!"

So, why am I also dismayed? Let me share one example of many that typifies our problem. A recent report on workers' compensation claimants from Florida is particularly galling. It pointed out that for industrial musculoskeletal injuries, chiropractic care demonstrates lower costs and shorter durations both in terms of reaching maximal medical improvement and return to work. Incredibly, over the same seven-year period, the frequency of specific musculoskeletal-related cases treated by chiropractors in 1999 was only 25 percent of the level seen in 1994 [the date that managed care was introduced into the Florida workers' compensation system].²⁰ In other words, just when workers' access to chiropractic care should be increased, to bring about significant direct and indirect cost savings [as previously shown by Manga²¹], we are witnessing precisely the opposite. Chiropractic care seems to be getting squeezed out of the system. Look at the neighboring state of Georgia, in which chiropractic workers' compensation cost recoveries were just 0.8 percent of the benefits disbursed to physicians in 1997 and 1998.^22,23 Again, one suspects the exclusion of chiropractic services.

Is this paranoia? Not when you consider that, despite the wealth of its research information with such little funding, it has been necessary time and time again for the chiropractic profession to seek legislation and legal recourse to achieve its earned recognition with the most meticulous of research. This necessity is ironic in light of a recent report which shows that chiropractic practices in at least one locale can demonstrate that a higher percentage of its treatments are evidence-based than found in medical interventions.²⁴ Yet we still endure the opinions of past editors of such trusted sources as The New England Journal of Medicine who have debunked alternative medicine as "unscientific," often basing their own theories on the same type of anecdotal evidence that they condemn in various branches of nonorthodox medicine.^25,26 Add medical journal articles on cerebrovascular accidents of questionable scientific validity,^27-32 plus an onslaught of negative press regarding the safety of manipulation,^33-38 that could only be described as a "Petri dish of fetid disinformation of the first magnitude." This is downright embarrassing, almost vaudeville, when you consider that medical practitioners have been shown to have failed validated competency examinations in musculoskeletal medicine.^39-41 Instead of abiding by this nonsense, we need to level the playing field instead of the patient!

In an ideal world, scientific debate would be carried on at a high level, and documented evidence would be enthusiastically accepted and incorporated into guidelines and practice. In the real world, unfortunately, there have been too many examples of resistance, such that chiropractic health care would probably not even have existed had such lawsuits as the Wilk case against the AMA for restraint of trade not been brought to bear.⁴² Now the profession faces discrimination in reimbursement practices in the insurance industry, requiring two more ongoing lawsuits, headed by the American Chiropractic Association (ACA), against Trigon Blue Cross Blue Shield and the Health Care Financing Administration.⁴³

How have the insurance industry and the AMA responded to appempts to control the costs of health care? By advocating such legislation as the "Help Efficient Accessible, Low-Cost, Timely Health Care Act" of 2003, designed to cap pain and suffering awards to patients suing for malpractice.⁴⁴ In light of the IOM's own data on iatrogenesis and medical errors,^2,3 and more recent reports that tell us that efforts to improve on these errors have not been forthcoming, and that their mandatory reporting has actually been resisted by doctors and hospitals,⁴⁵ this seems to be an exceptionally cynical and ill-conceived response to the needs of the American public. Equally as cynical and poorly conceived is the ignoring of the real culprit of runaway costs: runaway prescription drug spending.⁴⁶ Realizing already documented^21,47 cost savings by allowing patients access to alternative means of health care, including chiropractic, seems far more efficient and effective.

Chiropractic interventions that manifest tangible results; a commitment to research and documentation of the highest recognized quality;^15-17 high patient satisfaction; and cost-effectiveness should not have to continually resort to legislation and costly legal action to survive. In this presentation, I request that the IOM display a commitment to working with us to halt the spread of discriminatory policies which impede access to health care and the propagation of disinformation in the media that can only be described as an epidemic of alarming proportions. By "commitment," I am referring specifically to adequate, qualified chiropractic representation in matters of health care policy and decision-making, as we attempt to address the leading problems in America's health care. All too often, this effective seat at the table has been denied as part of the discriminatory pattern I referred to earlier. Skyrocketing health insurance premiums and the known shortages of health care professionals can be addressed with better access to chiropractic health care.

References

1. Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, 1999.
2. Institute of Medicine: Defining Primary Care: An Interim Report. Washington, DC: National Academy Press, 1994.
3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
4. Chassin MR, Galvin RW, National Roundtable on Healthcare Quality. The urgent need to improve healthcare quality. Journal of the American Medical Association 1998;280(11):1000-1005.
5. Goldstein M [ed]: Monograph No. 15. The Research Status of Spinal Manipulation. Washington, 1975, U.S. Department of Health, Education, and Welfare.
6. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, 1994, Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.
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22. www.ganet.org/sbwc/about
23. Smith JC. E-mail notice of Aug. 11, 2000.
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29. Bin Saeed A, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. The Canadian Journal of Neurological Sciences 2000;27(4):292-296.
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33. Brody J. When simple actions ravage arteries. New York Times, April 30, 2001.
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39. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. Journal of Bone and Joint Surgery 2002;84-A(4):604-608.
40. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. Journal of Bone and Joint Surgery 1998;80-A(10):1421-1427.
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42. Getzendanner S, District Judge, decision in Wilk v. AMA, 27 August 1987.
43. Cuneo GV. ACA's 2002 annual report. Journal of the American Chiropractic Association 2002;39(11): 20-32.
44. http://thomas.loc.gov/ described in Amednews.com, Feb. 27, 2003.
45. The Washington Post, Dec. 3, 2002.
46. Associated Press, Washington, DC, Jan. 8, 2003.
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Anthony Rosner, PhD
Brookline, Massachusetts
rosnerfcer@aol.com