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The Survey as Science ... Continued

Editor's note: The July 14 issue contained the following letter to the editor from Dr. Kurt Hegetschweiler, vice president of professional and governmental affairs for American Specialty Health. In his letter, he noted, "I have included patient satisfaction survey results of patients treated by ASH participating chiropractors in 2002." Those results, omitted from the letter DC originally published, appear in the reprinted version below.

Dear Editor:

American Specialty Health, Inc. (ASH) is concerned with DC's Feb. 18 ChiroPoll (www.chiroweb.com/chiro poll/03archive/2_18_03.html) regarding chiropractors and perceived patient attitudes toward managed care companies. While it is understandable wanting to survey practicing chiropractors regarding their attitudes on many issues, Internet polls are well-known to be highly unscientific, as you state with every poll you publish. It is difficult to define the sample, and a mechanism to eliminate multiple entries needs to be in place. Most importantly, the survey question needs to ask an appropriate question from the appropriate group. Thus, it is inappropriate to ask practitioners your question.

The only group that can answer this question appropriately is the patients who received chiropractic care from a network provider participating in the respective managed care company.

For your information, I have included the patient satisfaction survey results of patients treated by ASH participating chiropractors in 2002. An independent NCQA-certified company performs this national patient satisfaction survey annually using a HEDIS-validated survey instrument. The number of patients surveyed is 1,557. The results speak for themselves.

(Editor's note: A complex, if not comprehensive, description of the HEDIS survey procedures is available at www.ncqa.org/docs/hedis/100denomin.doc, viewable as a Microsoft Word document file.)

Kurt Hegetschweiler, DC
Vice President, Professional & Governmental Affairs
American Specialty Health
San Diego, California

Dear Editor:

Regarding Dr. Winterstein's article, "Chiropractic Genocide?" [June 16 DC], I couldn't agree more that the frivolous lawsuits for monetary gain are counterproductive and ill-aimed - but you have to agree, it's awfully funny for the CCE to attempt "homicide" on the large, fast-growing Life University, even after Dr. Sid Williams stepped down, and other changes were made as requested. After all, that must have been the goal of the CCE for years; after all, he was always voting against this and that and embarrassing the organization. But that's nowhere near the embarrassment caused by a high-profile school in our profession having its legs kicked out from under it.

A revoking of accreditation is much worse than a probation - and much more drastic. The CCE needs to account for its actions. If we do not know the specifics in this case, the CCE should be required to make them known.

Jeff Smith, DC
St. Simons, Georgia

Dear Editor:

As a board-certified chiropractic neurologist, I was intrigued by the article submitted by Dr. Masarsky in the June 2, 2003 issue: "Shrinking Blind Spot." Although Dr. Masarsky is accurate in assuming a physiological blind spot can be a valuable diagnostic tool in evaluation and treatment parameters for chiropractors, he neglects to back his assumptions with scientific explanation that could be found in peer-reviewed, indexed literature. Unfortunately, the "pinched nerve" treatment of the upper cervical region is not the "evidence-based education" that would hold up in the scientific community.

A physiological blind spot is a consequence of isolating thalamic integration and neocortical compensation for optic nerve penetration of the retina. The blind spot is mapped using a focal testing point with each eye separately. As the patient focuses on this point, while occluding the contralateral visual pathway, the examiner maps the "blind spot" by using a point like a red marker tip. The examiner will have the patient state when the point "disappears" from his or her peripheral vision. This is done in multiple quadrants (usually 8 or more points) and will create an area that can be filled in as a blind spot for each eye. This finding cannot be used by itself for diagnostic information, but rather as another physical exam finding that must be correlated with a thorough neurological examination of the entire body. It is often found that an enlarged blind-spot is in concert with a functional hemisphericity of the neocortex. If it is found that the hemisphericity and blind spot enlargement coincide, a chiropractor can increase the large-diameter afferentation from the contralateral side to increase the probability of thalamic summation and neocortical afferentation that would improve functional balance of the central integrated state. This can be achieved with a variety of mechanoreceptor afferentation techniques, but it is important to note that this must be done in a way not to exceed the metabolic capacity of the patient. Because upper-cervical receptor population is so great, adjustments to this region may be contraindicated until the patient has better central integrative balance and autonomic capacity. It also is important to be side-specific when addressing these autonomic concomitants, because generalized manipulation can create a hemisphericity, and even lead to permanent neurological damage, such as a vascular accident.

It is also important to note that a smaller blind spot may not always correlate to the side of better neurological integrity and would be deliterious to the patient to adjust on the contralateral side of the enlarged blind spot. An example of this would be a patient with basal ganglionic demise, which often presents with a "pinhole" type of blind spot on the side of hemisphericity, reinforcing the fact that the physician must complete and correlate with an entire neurological evaluation.

Although blind-spot maps are a valuable and cost-effective means of diagnosing our patients, it is important for chiropractors to be educated in areas of "thalamic integration" and "functional neocortical hemisphericity." These terms are well-researched and represented in neurological journals. If the physician is not familiar with the effects of the adjustment on these areas of the central nervous system, I recommend referring to a board-certified neurologist for assistance in an efficacious treatment plan that would be in concert with your patients' neurological needs, and to not just manipulate the upper cervical complex to see what happens to their blind spots.

Trevor Berry DC, DACNB
Tempe, Arizona

Dear Editor:

In reference to your article, "Ain't Got Enough Philosophy" (Dr. Joseph Keating, June 16): At a recent chiropractic function, a dear friend of mine said something very powerful that is worth sharing.

We should all accept chiropractic unconditionally. Once we accept this, there is no reason to pit one school against another, or one chiropractor against another. The division that is being created is not necessary; it is not a question of what principles chiropractors ought to accept and what should be modified or discarded.

Angelika Koeth, DC, FICPA
Milton, Ontario
Canada

Dear Editor:

A recent article in the WCA Journal shows just how far some will go for their dogma. It glowingly stated its pride behind a bill to strip chiropractic physicians of their "physician" title in Medicare language. What kind of ignorant move is that? This bill would "remove 'chiropractor' for the Medicare definition of physician...and include specific reference to the services provided by DCs." This would do nothing but further limit our services, and decrease our status of physician to that of a "primary care portal-of-entry health-care provider" - that's the equivalent of a triage nurse! This obviously fits in with the "adjust-only" ilk that wants chiropractic physicians to do nothing more than adjust subluxations. While they state they are not opposed to incorporating "extra-chiropractic therapies" into our practices, these therapies must meet their criteria. We've all been trained to diagnose and treat in chiropractic college.

Should this bill pass, there is a distinct possibility that referrals for diagnostic imaging (from DCs) would be in peril. Many of these need a "physician" referral, from which we may be barred, possibly putting our patients at risk. If these "adjust-only" DCs are true to their word, why not promote federal legislation stating, "The scope of practice of chiropractic shall be those diagnostic and treatment procedures taught by an accredited chiropractic college"? This guarantees those DCs who only want to adjust subluxations to do so, while allowing others to treat and diagnose to the extent we were taught and trained. Don't the "adjust-only" DCs espouse a live-and-let-live policy of practice? If a DC wants to practice by only adjusting his or her patients' subluxations, he or she should have every right to do so. However, those of us who wish to pursue a more wide-ranging scope of practice, just as we were taught, should have that right.

Gregory Katsaros DC, DAAPM
Tempe, Arizona

Dear Editor:

I have been reading the various calls to unity brought forth in this publication. I think your publication is fair in expressing all the views involved.

I am writing this letter to make the point that the way I practice, objective straight chiropractic, tends to be completely overlooked and misunderstood. In my opinion, subluxation-only is the broadest scope, not the narrowest. It is based on the vitalistic concept and deductive reasoning that your body is better off without a subluxation.

This is what is taught to the practice member, and each is free to choose. Some use their inborn recuperative abilities to heal from a condition only; some use it as prevention; and some use it as I do - for health and wellness for the entire family. The method is the chiropractic adjustment.

Albeit, not many insurance companies pay for care just based on the subluxation, it is a viable way of practice independent of third-party pay. I think if all practitioners, including the therapeutic chiropractor, would charge what a person would pay out-of-pocket, plus perhaps their servicing costs, to the insurance company or to the consumer, I bet we would find many who would pay.

Before insurance, more practitioners failed than made it, but the ones who did make it seemed to have an inner strength and conviction regarding chiropractic care they could pass it on to other practice members.

If a practitioner is looking for a new way to practice, in my opinion, subluxation-only care is rational, broad-scope, and just plain fun!

Jay Yuhas, DC
Metuchen, New Jersey

Dear Editor:

In the June 30 issue of DC, we were asked what the chiropractor of the future would look like. [See the publisher's report of findings.] As a DC who views himself as a "straight," I often become annoyed with both our community and the "mixer" community. The straights spout philosophy and innate stuff, and it comes off as unscientific. All the while, the mixers seem to embrace the medical model of health care that I call "allopathic-lite health care."

We have national organizations that jockey for political advantage and promote their style of chiropractic, while many of us practicing in the real world avoid them because of the games and BS. If this foolishness doesn't stop, we will end up like the osteopaths, being absorbed by medicine, and becoming nothing more than MDs with different letters behind our names. We can toss in a little manipulation to prove we are unique, but we won't truly be unique any more!

The mixers need to stop pushing chiropractic education in the medical direction, and the straights need to put philosophy where it belongs - as a small part of the practice, instead of the focus.

We need to be the best students in anatomy and physiology, and there is no excuse if we are not, considering that structure dictates function. For some reason, both sides avoid this, and I can only surmise that it is out of fear that it will go somewhere each group does not wish to go.

I would like to see a major scientific effort in just two places before I retire (or die): The first would be a major study examining the work of Dr. A.D. Speransky. He examined the connection between the spine and nerve interference and disease. Read his book, A Basis for the Theory of Medicine, and discover what he said; it will open your eyes!

The second study would be to prove the effects of chiropractic adjustments, and would entail the use of thousands of clinical trials using X-rays and CT and MR imaging studies, examining the changes in all three imaging methods to prove (or disprove) the core concept of the subluxation being a major nerve interference factor in disease. This would also have the effect of proving or disproving that dissection aneurisms do or do not occur during the cervical adjustment. The human body, especially the spine, is dynamic, and viewing it in a static format does not provide the scientific information we all need to validate our beliefs - which seem to be proven every day by clinical experiences - but there is nothing like visual scientific proof of our point to enhance our standing in the scientific community.

This is my challenge to the ACA, the ICA and all the other splinter organizations with the body chiropractic: Do the research, no matter where it leads us! I have faith that it will validate the subluxation in a new way and make us the primary care doctors we should be.

James Watson, DC
Canandaigua, New York

Dear Editor:

Regarding the "Wall Street Journal Questions Chiropractic - Again" article [July 14], I don't suppose anyone is surprised. If you are, here's a quick reality check:

The Wall Street Journal (WSJ) is a newspaper that caters to people who want to make money. The pharmaceutical industry is a multibillion-dollar behemoth that provides huge profits in stocks and generates a large amount of advertising revenue to all media. The money to be made by investing in chiropractic, by comparison, doesn't exist. If you think, for even a moment, that the editors of the WSJ can be objective about this, I have a bridge you might be interested in purchasing.

The WSJ wouldn't care about chiropractic, except more and more patients are seeing chiropractors and not taking drugs. New studies demonstrating chiropractic's effectiveness are being published with increasing frequency. MDs are referring to chiropractic with increasing ease. And it's bad enough that these MDs are probably prescribing fewer drugs as a result - imagine the consternation in the drug industry boardrooms when chiropractors were made primary portal-of-entry physicians in HMOs. Coupled with the recent successes in obtaining chiropractic access for military personnel (another huge market), you can bet drug industry bigwigs have been plotting to discredit chiropractic for years! Nothing like success makes your enemies sit up and take notice.

So - any study, no matter how poorly done, that can be used to discredit chiropractic - will be lifted on high and trumpeted with all available media fanfare. Science is not the issue here; it's all about the money!

What can we do about it? Trumpet the truth! If your patients ask about it, tell them the WSJ is an unreliable source of information about chiropractic. Our longtime foe, Steven Barrett, MD, is rapidly losing his credibility. Until and unless the WSJ gets these "news flashes" right the first time, it has no credibility, either.

Roger Berman, DC
Northampton, Massachusetts