Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient
By Anthony Rosner, PhD, LLD [Hon.], LLC
In a letter to Bishop Mandell Creighton in 1887, Lord Acton penned the oft-cited expression, "Power tends to corrupt, and absolute power corrupts absolutely." Nowhere has this principle been more evident in our health care system than in our failure to displace the status quo - denying patients greater satisfaction, better outcomes and cost savings.
It boggles the mind to realize that there exist concrete examples where compelling evidence exists to admit alternatives to the health care marketplace, yet patients are often neither empowered with nor aware of the possible effectiveness of these alternatives.
To paraphrase a popular expression from the "Dirty Harry" (Clint Eastwood) movies, unmasking just a few allegedly sacred truths in health care might just "make your day." These undoubtedly have tremendous bearing upon the status and potential of chiropractic health care delivery worldwide:
Effective and economical delivery systems of health care are denied access despite inferior and costly performance by the gatekeepers. In a presentation to a recent convention addressing the economics of health care,1 Pran Manga described how physician assistants and dental hygienists, whose qualifications and capacities for effective management in many areas equal or exceed those of medical doctors or dentists, respectively, are denied access to many patients - despite the fact that their services may be delivered at one-third the cost of conventional caregivers. In terms of chiropractic services, an impressive aggregate of scientific literature exists to demonstrate both its effectiveness2-4 and cost-effectiveness, yet barriers continue to plague chiropractors5 despite the fact that (i) the formal hours of training in professional schools in the didactic areas are about the same for MDs and DCs,6 and (ii) orthopedic residents - presumably representing the most musculoskeletal-savvy individuals of allopathic medicine - have received failing scores in musculoskeletal competency examinations, verified by the chairmen of the departments of either orthopedic7 or internal8 medicine.
The relative risks of chiropractic versus medical or dental procedures are vastly overblown: The hysteria with which the medical literature9-11 and press12 have reported the risks of chiropractic procedures has been the subject of previous reports from my desk. Published death rates from cervical manipulation - on the order of three per 10 million adjustments13 or even less14 - turn out to be no greater than those reported for dying from falling out of bed,15 dying from a series of dental x-rays,16 or drowning in a bathtub.16 Meanwhile, it can be demonstrated that the most plausible rates of stroke reported for cervical manipulations, ranging anywhere from 0.613 to 2.5 per million,17 are 17-50 times less than the rates of spontaneous cervical or carotid artery dissections.18-20
When one begins comparisons with medical procedures, the statistics really begin to spin one's head. Using a baseline figure of one per one million as an estimate of stroke incidence attributed to cervical manipulations, one finds a:
two times greater risk of dying from transfusing one unit of blood;16
100 times greater risk of dying from general anesthesia;16
160-400 times greater risk of dying from use of NSAIDs;21
700 times greater risk of dying from lumbar spinal surgery;22
1000-10,000 times greater risk of dying from traditional gall bladder surgery;16
10,000 times greater risk of serious harm from medical mistakes in hospitals.16
The 225,000 deaths per year attributed to medical iatrogenesis have propelled it to the third leading cause of death, after heart disease and cancer.23 A truly eloquent examination of the relative risks that our population deems "acceptable" - all far above those numbers reported for spinal manipulation - has been published recently by Rome.24
Many accepted medical practices are in a constant state of flux, almost approaching fad status. That medical practices often seem to follow fashion rather than unassailable standards extensively documented in recent articles. Breastfeeding, botox, leeches, and electroshock therapy - all taboo for extended periods during the 20th century - have made significant comebacks in clinical circles.25 Long-term hormone replacement therapy to manage osteoporosis or hot flashes during menopause has recently been suggested to increase the rates of deep-vein thrombosis, pulmonary embolism or biliary tract surgery,26-28 while mammograms may not reduce mortality in breast cancer after all.29 Within the past few months, arthroscopic surgery has been shown to be no more effective than sham surgery in treating osteoarthritic knee problems.30 Finally, how could we fail to mention that the authoritative Merck Index just 100 years ago recommended formaldehyde for treating the common cold, ammonia for male baldness, smoking for asthma, opium for alcoholism, and strychnine for treating diphtheria?31
From the physician's point of view, guidelines continue to proliferate, but are often ignored. Even in the medical journals, one has to sit up in stark amazement when such a medically entrenched publication as the Canadian Medical Association Journal concludes something chiropractors have maintained for decades: "Treatment of musculoskeletal pain should focus on the underlying cause, and in many cases, the use of any anti-inflammatory drug is inapproprate."32
The only problem is that the same article blows its cover by laying out options that omit any reference to spinal manipulation, concluding: "Nonpharmacologic treatments, including strengthening and stretching exercises, ice or heat are often underused." It is tempting to imagine what the authors would have said about spinal manipulation, if only they could remember the lyrics. This "amnesia" of spinal manipulation, unfortunately, is nothing new, having been shown previously in guidelines from Harvard33 and the AMA -34 in clear violation of the principles of informed consent, elegantly articulated and upheld in the New Jersey Supreme Court,35 and discussed at length in this space previously.36
This leaves the patient with every justification to demand more empowerment, including greater access to diverse and qualified health care providers - including chiropractors. With the vast majority of medical therapies having never been evaluated by a systematic study, many prevailing practices become that way more because of belief, political power and repression. As implied by Kevin Patterson, the tendency to accept surgical alternatives, for example, could be linked to the age-old axiom, "Never let the sun set on an abscess (i.e., operate immediately)." Absolute, testosterone-charged, black-and-white statements by heroic physicians will have to give way to the grey world of numbers brought to us by evidence - rather than eminence-based medicine.37
Health care or wealth care: Is it all about money? Healthcare economics conference, Vancouver, British Columbia, Canada, September 16, 2002.
Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Annals of Internal Medicine 2002;136:216-227.
Meeker WC, Mootz RD, Haldeman S. Back to basics: The state of chiropractic research. Topics in Clinical Chiropractic 2002;9(1):1-13.
Rosner AL. Musculoskeletal research. In: Redwood D, Cleveland C. Fundaments of Chiropractic. New York, NY: Churchill Livingstone, in press, 2002.
Gaumer G, Koren A, Gemmen E. Barriers to expanding primary care roles for chiropractors: The role of chiropractic as primary care gatekeeper. Journal of Manipulative and Physiological Therapeutics 2002; 25(7):427-449.
Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education. Alternative Therapies in Health and Medicine 1998;4(5):64-75.
Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. Journal of Bone and Joint Surgery Am 1998;80-A(10):1421-1427.
Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. Journal of Bone and Joint Surgery 2002;84-A(4):604-608.
Morley J, Rosner AL, Redwood D. A case study of misrepresentation in the scientific literature: Recent reviews of chiropractic. Journal of Alternative and Complementary Medicine 2001;7(1):65-78,79-82.
Rosner A. Chiropractic: More good than harm or vice versa? Journal of Manipulative and Physiological Therapeutics 1999;22(4):250-253.
Rosner A. Chiropractic manipulation and stroke (letter to the editor), Stroke 2001;32(9):2207-2208.
Rosner A. The enduring qualities of Loony Tunes. Dynamic Chiropractic April 22,2002;20(9).
Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine 21(15):1746-1760.
Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: The chiropractic experience. Canadian Medical Association Journal 2001;165(7):905-906.
USA Today, September 12, 1999 and the Associated Press, December 3, 1999.
Paling J. www.healthcare speaker.com, 2000.
Dvorak J, Orelli F. How dangerous is manipulation of the cervical spine? Manual Med 1985;2:1-4.
Shievink WT, Mokri, B, O'Fallon WM. Recurrent spontaneous cervical-artery dissection. New England Journal of Medicine 1994;330(6):393-397.
Shievink WT, Mokri B, Whisnant JP. Internal carotid artery dissection in a community: Rochester, Minnesota, 1987-1992. Stroke 1993;24(11):1678-1680.
Giroud M, Fayolle H, Andre N, Dumas R, Becker F, Martin D, Baudoin N, Krause D. Incidence of internal carotid artery dissection in the community of Dijon (letter). Journal of Neurology and Neurosurgical Psychiatry 1994;57(11):1443.
Dabbs V, Lauretti W. A risk assessment of cervical manipulation vs NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiolgical Therapeutics 1995;18(8):530-536.
Deyo RA, Cherkin DC, Loesser JD, Bigos SJ, Ciol MA. Morbidity and mortality in association with operations on the lumbar spine: The influence of age, diagnosis, and procedure. Journal of Bone and Joint Surgery Am 1992;74(4):536-543.
Starfield B. Is US health really the best in the world? Journal of the American Medical Association 2000;284(4):483-485.
Rome PL. Perspective: An overview of comparative considerations of cerebrovascular accidents. Chiropractic Journal of Australia 1999;29(3):87-102.
Patchett A. Estrogen, after a fashion. New York Times Magazine, July 28, 2002, pp. 11-12.
Grady D, Herrington D, Bittner V, Blumenthal R, Davidson M, Hltaky M, Hsia J, Hulley S, Herd A, Khan S, Newby LK, Waters D, Vittinghoff E, Wenger N. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study followup (HERS II). Journal of the American Medical Association 2002;288(1):49-57.
Hulley S, Furberg C, Barrett-Connor E, Cauley J, Grady D, Haskell W, Knopp R, Lowery M, Satterfield S, Schrott H, Vinttinghoff E, Hunninghake D. Noncardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). Journal of the American Medical Association 2002;288(1):58-66.
Pettiti DB. Hormone replacement therapy for prevention: More evidence, more pessimism. Journal of the American Medical Association 2002;288(1):99-101.
Kolata G. Putting mammograms to the test. Available at www.nytimes.com.
Mosely JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine 2002;347(2):81-88.
Merck's 1899 Manual, or the Materia Medica. New York, NY: Merck & Co., 1899.
Wooltorton E. What's all the fuss? Safety concerns about COX-2 inhibitors rofecoxib (Vioxx) and celecox ib (Celebrex). Canadian Medical Association Journal 2002;166(13).
Acute low back pain. Best Practice in Brief (Harvard Pilgrim Health Care Clinician Education Program) 1999;1(1).
AMA Editorial Board. AMA's Pocket Guide to Back Pain. New York, NY: Random House, 1995.
Jean Matthies v. Edward D. Mastromonaco, D.O. Supreme Court of New Jersey (A-9-98), Pollock J, Judgment dated July 8, 1999.
Rosner AL. Matthies v. Mastromonaco, D.O: The right to be informed, or research findings come home to roost. Dynamic Chiropractic March 25, 2000,18(13).
Patterson K. What doctors don't know (almost everything). New York Times Magazine, May 5, 2002.