Articles by JCS

CNN's Fairness Doctrine

 

August 29, 2011

Richard Davis

CNN EVP

One CNN Center

Atlanta, GA 30303

 

RE: Conflict of Interest Complaint

Dear Sir:

In your capacity as CNN's executive vice president of News Standards and Practices “to ensure that CNN Worldwide's on-air reports and programs are fair, accurate and responsible,” I am writing to you concerning unethical journalism by Dr. Sanjay Gupta.

As a 33-year practicing chiropractor, I must complain about two glaring issues: First is his apparent boycott and misrepresentation of the chiropractic profession—the third-largest physician-level health profession in the nation as well as the foremost non-surgical spine care providers and professional rivals to Dr. Gupta.

Secondly, Dr. Gupta has avoided a remarkable controversy about his own profession—the rise of unnecessary spine surgeries—despite other news media that have recently jumped on this exploding topic.

Let me explain these current issues in spine care that will give you some essential background to my complaint.

This is an escalating issue that has undergone heavy scrutiny in this era of rising costs and evidence-based healthcare. Not only will 8 out of 10 adults suffer from acute low back pain some time in their lives, it is the most disabling condition in the workplace and has become a $100+ billion industry.

Aside from the enormity of the back pain epidemic, new research and recent media reports show back surgeries are often unnecessary and over-used. Moreover, researchers using MRI studies now show spine fusions are based on a disproved disc theory. Presently there is a Senate investigation on spine surgeons plagued with perverse motivations and device manufacturers accused of financial corruption. Yet we have heard nothing from Dr. Gupta on these newsworthy stories.

The problem, I believe, is the fact that Dr. Gupta, a neurosurgeon, has a conflict of interest since his profession competes with chiropractors for many types of back pain cases. It is well known that spine surgeons have an ingrained bias toward chiropractors, the subject of my latest book,[1] and Dr. Gupta’s action to ignore chiropractors typifies the tactics of the AMA in the medical war against chiropractors to see them “wither on the vine.”[2]

As well, his medical bias, whether knowingly or unknowingly, has become an impediment to the public’s understanding regarding the controversy regarding MRI scans and spine surgeries, and the significant guideline changes that have occurred in the last few years that have conspicuously gone without comment by Dr. Gupta and CNN.

Indeed, there is a huge scandal in spine care medicine that most every major media has broached, but not CNN. It is simply implausible for this to be simply an oversight. Please give me a moment of your time to introduce research and media reports that support my two complaints about the reporting or lack thereof by Dr. Gupta.

1) Exaggerated Medical Allegations

I realize the Fairness Doctrine and Equal Time concepts are not the federal law anymore, but ethical journalism should still apply when the reporting is directed to hotly debated health policies as we saw with Obamacare.

Realizing I have never seen any program on CNN concerning the benefits of chiropractic care, I searched the CNN website for programs by Dr. Gupta and the only one I found was a short video that shamelessly smeared my profession with an exaggerated allegation that chiropractic care has caused hundreds of strokes:

  • Stroke after chiropractic care updated Wed June 25, 2008
  • Hundreds of people have had strokes after having their necks manipulated. Dr. Sanjay Gupta reports.

http://www.cnn.com/video/#/video/health/2008/06/25/gupta.chiro.stroke.cnn

However, the facts belie Dr. Gupta’s claim. Let me provide scientific proof rather than personal opinion to show his comments were an obvious violation of the fair journalism.

According to research by Alan Terret et al., the rate of iatrogenic problems associated with spinal manipulative therapy as rendered by doctors of chiropractic is only 1 in 5.85 million cases, which is less than the chance of stroke in a hair salon or being hit by lightning (one in 600,000). It equated to one occurrence in 48 chiropractic careers.[3]

“We didn’t see any increased association between chiropractic care and usual family physician care, and the stroke,” said Frank Silver, one of the researchers and also a professor of medicine at the University of Toronto and director of the University Health Network stroke program. [4]

The findings, which were published in the journal Spine,[5] helped to shed light on earlier studies that had cast a cloud on the chiropractic profession and suggested that their actions resulted in some patients suffering a stroke after treatment. In fact, the findings support the chiropractic position of its extreme safety when compared with drugs and neck surgery.

A study by Anthony Rosner, PhD, comparing medical procedures to chiropractic care concerning strokes mentions patients need to be warned of the dangers of medical procedures rather than chiropractic care. As he suggests, “The statistics really begin to spin one's head.”[6]

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;[7]
  • 100 times greater risk of dying from general anesthesia;[8]
  • 160-400 times greater risk of dying from use of NSAIDs;[9]
  • 700 times greater risk of dying from lumbar spinal surgery;[10]
  • 1000-10,000 times greater risk of dying from traditional gall bladder surgery;[11]
  • 10,000 times greater risk of serious harm from medical mistakes in hospitals.[12]

Obviously Dr. Gupta failed to report the corresponding dangers of medical care when he embellished the danger from chiropractic care, a tactic used by the illicit Committee on Quackery in the 1960s by the AMA to defame chiropractors.

Despite the overwhelming evidence of the comparative safety of chiropractic manipulation for neck problems, a dubious study from England, “Deaths After Chiropractic: A Review Of Published Cases,” by Edzard Ernst of the Medical School at the University of Exeter, once again raised the level of fear over chiropractic care when he noted that “Twenty-six fatalities were published since 1934 in 23 articles.”[13]

Considering this covers 77 years and equates to 0.34 deaths per year, instead of sounding an alarm, Ernst should have praised chiropractic care for its obvious safety since this is an extremely low rate in comparison with equivalent medical methods such as neck surgery that has shown a 3-4% rate of complications for cervical spine surgery. Estimates suggest this equates to 4,000-10,000 deaths per million neck surgeries.[14]

Obviously Dr. Gupta’s video about chiropractic care causing “hundreds” of strokes is untrue when, in fact, it equates to one-third of a person annually, yet he has made no attempt to correct his misinformation nor did he inform his audience of the thousands who die from spine surgery annually.

If we were to take a look at the rates of iatrogenic deaths from medical care, the numbers are staggering, another fact Dr. Gupta has ignored. Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, reported that medical care is now the third-leading cause of death in the U.S., causing 225,000 preventable deaths every year. [15]

Obviously distorting the facts does not inform today’s health care consumer of the safety or efficacy of chiropractic care, clearly indicating his lack of objectivity and fair journalism.

Medical Incompetence in Back Pain Cases

Ironically, while people are led to believe MDs are experts in back problems, this was shown to be another falsehood. In fact, testimony and research now shows primary care medical physicians are ill-trained in musculoskeletal disorders, another noteworthy story ignored by Dr. Gupta, but not by some of his colleagues.

Scott Boden, MD, currently director of the Emory Orthopaedic and Spine Center in Atlanta, admits that  “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”[16]

This belief is supported by the consensus that the poor medical outcomes stem from an antiquated disc theory in that MRIs detect incidental anatomical findings, ineffectual medical treatments consisting of drugs, epidural steroid injections, and primary care physicians who are ill-trained to diagnosis. Compounding this medical mess is their bias that refuses to refer these cases to non-surgical primary spine care practitioners such as chiropractors.

 Indeed, the major obstacle to overcome in this epidemic of back pain originates from misdiagnosis and mistreatments by medical doctors themselves.

The fact that most MDs are poorly educated in this field was revealed at the federal antitrust case, Wilk et al. v. AMA et al., during the testimony of Dr.  John C. Wilson, one-time president of the American Academy of Orthopedic Surgeons. In his paper published in 1967, he admitted to medical “prejudices and controversies” that hinder proper spinal care:

At the postgraduate level, symposia and courses concerning the cause and treatment of low back and sciatic pain are often ineffective because of prejudices and controversies. Even the abundant and significant advances resulting from the medical profession’s emphasis upon research have failed abysmally to relieve modern man of one of his most common and bothersome afflictions, low back pain.[17]                        

John McMillan Mennell, MD, prominent author and instructor at eight different medical schools during his career, also testified that most medical graduates spent only “zero to about four hours” studying problems of the musculoskeletal system.[18]

Dr. Mennell also enlightened the court as to the value of spinal manipulation during his testimony at the Wilk trial:

Eight out of ten patients that come out of any doctor’s office complain of a musculoskeletal system problem, regardless of what system the pain is coming from…I will say 100 percent of those complaints…are…due to joint dysfunction in the musculoskeletal [system]…If you don’t manipulate to relieve the symptoms from this condition of joint dysfunction, then you are depriving the patient of the one thing that is likely to relieve them of their suffering.[19] (emphasis added)

In 1998, Kevin B. Freedman, MD, and Joseph Bernstein, MD, published a landmark study in Journal of Bone and Joint Surgery wherein they administered a validated musculoskeletal competency examination to recent medical graduates from 37 medical schools who had begun their hospital residency; 82 percent of these medical doctors failed to demonstrate basic competency on the examination, leading the authors to conclude, “We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.” [20]

Even those physicians with a special interest in low back pain were more likely to believe in outdated concepts such as narcotics, complete bed rest, and avoidance of work for acute low back pain—concepts now regarded as inappropriate. Oddly, there were no important differences in back pain beliefs between those with and without a special interest in musculoskeletal medicine.[21] It appears that any MD with an interest in back pain can hang out a “back pain clinic” shingle even when poorly trained in this area.

A study published in Spine scored the content of the family physician-directed care and found it to be “highly guideline-discordant.” The three studies by Bishop et al. provide an excellent illustration of the slow pace of implementation of evidence-based spinal care into primary care settings.

“Typically, the family physician-based care involved excessive use of passive therapies such as massage and passive physical therapy, excessive bed rest, and excessive use of narcotic analgesics,” said Paul B. Bishop, DC, MD, PhD, Clinical Associate Professor in the Department of Orthopaedics at University of British Columbia. [22]

The research shows most MDs are ill prepared to deal with musculoskeletal disorders, an issue the public needs to be aware of, but a fact that Dr. Gupta has failed to report. Certainly you now understand my torment about Dr. Gupta’s avoidance of the chiropractic profession, when he misleads the viewers about its safety, or when he fails to reveal the incompetence of most MDs concerning back pain problems.  Again, this is not fair journalism.

2) Call for Restraint over Back Surgeries

My second complaint is directed to another important issue—the rash of criticism about spine surgeries that Dr. Gupta has ignored.  In this era of evidence-based medicine, numerous MRI studies have shown the disc theory is quickly dying, but kept alive by spine surgeons.

The first study on the disassociation between disc abnormalities and back pain was done by an Emory researcher, Scott Boden, MD. This renaissance in spine diagnosis began in 1990 when research by Boden et al.[23] followed in 1994 by a supportive study by Maureen Jensen et al.[24] found no clear correlation between disc abnormalities and back pain.

Yet this dubious theory remains very much alive today via the “slipped disc” diagnosis used by spine surgeons despite the fact that many people with pain have perfectly healthy discs. Richard Deyo, MD, MPH, has dubbed abnormal discs as “incidentalomas” since pain-free people have them.[25] Indeed, most non-specific low back pain is now considered due to joint dysfunction, which explains why chiropractic spinal manipulation works so well to restore joint play as Dr. Mennell testified.

The revelations about unnecessary spine disc fusions continue to appear in the mainstream media with the recent cover story in Newsweek magazine, “No! The One Word that Can Save Your Life” by Sharon Begley (August 22, 2011).

The article spoke about many unnecessary surgeries, including spine surgery based on the abnormal disc theory:

“…That’s because the ‘abnormalities’ seen in an MRI often have nothing to do with the back pain (people without pain have them too), but seeing something on a scan makes a physician feel compelled to get rid of it. “There is a long-standing fallacy among physicians that if you find something different from what you perceive to be ‘normal,’ then it must be the cause of the patient’s problem,” says UNC’s Hadler. (emphasis added)

Indisputably, MRI scans are used as an effective selling point and have greatly increased the number of unnecessary surgery. “In fact,” according to Richard Deyo, back surgery rates are highest where MRIs are the highest. In a randomized trial, we found that doing an MRI instead of a plain x-ray led to more back surgery, but didn’t improve the overall results of treatment.”[26]  

A 2009 Stanford University study also found the abundance of MRI scans lead to excessive back surgeries.  According to Stanford University Medical Center,[27] patients who live in areas with more MRI scanners are more likely to undergo spine surgery. “The worry is that many people will not benefit from the surgery, so heading in this direction is concerning,” said senior author Laurence Baker, PhD. [28]

Unquestionably, the need for a paradigm shift in spine care is gaining media momentum. The call for restraint in spine surgery has grown louder since spine fusion is now considered by many medical researchers among the biggest medical scams as well as the most expensive surgery in America. This is the professional opinion of many orthopedists.

Gordon Waddell, DSc, MD, FRCS, and director of an orthopedic surgical clinic for over 20 years in Glasgow, Scotland, has determined that back surgery is mostly ineffective, unnecessary, and disabling:

“Low back pain has been a 20th century health care disaster. Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem...It [back surgery] has been accused of leaving more tragic human wreckage in its wake than any other operation in history.”[29]

In the era of evidence-based healthcare, the facts clearly do not support the massive amount of spine surgeries, yet Dr. Gupta has ignored this call for reform. Over the last few months, the mainstream media has jumped on the unnecessary, risky, and expensive spine surgery scam.

For example, here are a few recent media exposés on spine surgery:

  • “Surgery May Not Be the Answer to an Aching Back,” by Joanne Silberner, NPR, April 6, 2010.
  • “Back Surgery May Backfire on Patients in Pain,” by Linda Carroll, MSNBC, Nov. 14, 2010
  • “Top Spine Surgeons Reap Royalties, Medicare Bounty,” by John Carreyrou and Tom McGinty, Wall St. Journal, Dec. 20, 2010
  • “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies” by Peter Waldman and David Armstrong, Bloomberg News, Dec. 30, 2010.
  • “Spinal Fusions May Cause More Harm Than Good,” by Terrance Pagel, Daily Health Report, Jan. 20, 2011
  • “Medicare Records Reveal Trail of Troubling Surgeries” by John Carreyrou and Tom McGinty, Wall St. Journal, March 29, 2011

I find it odd the CNN ignores this serious medical controversy while The Wall Street Journal, NPR, MSNBC, and the Bloomberg News have exposed the ineffectiveness, greed, and questionable disc theory behind spinal surgery. These articles also spoke of the untold cost in human suffering as well as wasted revenues of these unnecessary surgeries.  

Imagine the lower healthcare costs with the use of non-surgical treatments as experts now suggest. Beginning with the US Public Health Service’s guideline on acute low back pain in 1994[30], more recent guidelines including the North American Spine Society[31], the American Pain Society[32], and the Milliman Care Guidelines®[33] recommend spinal manipulation therapy as a first avenue for treatment and spine surgery as the last option, a point lost to most MDs.

The obvious question remains: why hasn’t Dr. Gupta or another CNN special documentary covered this huge spine controversy, the call for reform, the ruse of the disc theory, or the recommendations for spinal manipulation? I believe medical bias is the main reason. Just like racial prejudice, the medical bigotry toward chiropractors is deeply ingrained into most MDs.

Another paradigm shift to spine surgeons occurred when Blue Cross Blue Shield of North Carolina announced in January, 2011, that it would no longer pay for spinal fusion for back pain in the presence of only disc degeneration or disc herniation. This is a huge policy change that will hopefully have a ripple effect among all state BC/BS and other insurance companies to curtail payment for this epidemic of ineffective spine surgery. [34]

Yet, there has been no mention of this remarkable policy change by Dr. Gupta. Considering heart and back surgeries are the two largest revenue streams in hospitals, his omission continues to raise questions—why he refuses to report these landmark changes in spine care and insurance coverage that could greatly lower healthcare costs?

Moreover, both the WSJ and the New York Times in June, 2011, spoke of a Senate Finance Committee investigation of spine surgeons who received large sums of money from medical-device giant Medtronic Inc. for consulting and promoting the use of pedicle screws widely used in spinal fusion surgery.

The WSJ reported Medtronic paid Dr. Thomas Zdeblick, an orthopedic surgeon at the University of Wisconsin School of Medicine and Public Health, $19 million from 2003 to 2007, according to information made public by Sen. Grassley in 2009.[35] Yet Dr. Zdeblick has denied any influence by Medtronic.

This was another newsworthy issue ignored by Dr. Gupta; undoubtedly it would prove embarrassing for him and his colleagues if the public knew about the perverse motivation that fuels spine surgeries. For example, the average annual salary of a spine surgeon is now the highest paid of all doctors at $806,000 according to Bloomberg News.[36] This salary does not include the royalties and commissions paid by surgical hardware manufacturers like Medtronic that often top the million dollar level as the WSJ revealed in its article, “Top Spine Surgeons Reap Royalties, Medicare Bounty.”[37]

Nor has Dr. Gupta mentioned the monumental changes in treatment policy by national and international guidelines that recommend chiropractic care for non-specific low back pain. As well, he has ignored the positive public surveys in favor of chiropractors (Gallup[38], TRICARE[39], Consumer Report[40]), the comparative international studies recommending manipulation over drugs, shots, or surgery (AHCPR-US[41], Manga-Canada[42], NICE-UK[43]), and the researchers I’ve already mentioned who chide the disc theory as “incidentalomas” (Boden, Deyo, Jensen).

As you can see, the spine surgery scandal is huge, and has led to thousands of unnecessary spine surgeries performed each year costing millions in lost work days, billions of dollars in medical expense, as well as the incalculable human toll in suffering and depression by patients who never needed a spinal fusion. This also contributes to the drug addiction we now face in the so-called Hillbilly heroin epidemic of patients who now seek intervention from failed back surgeries.

Considering the enormous scope of this spine scandal, Sanjay Gupta has completely ignored this troubling situation that affects hundreds of thousands of back pain patients annually and costs the healthcare system billions of dollars. While Newsweek and other national news organizations are criticizing this spine scandal, why hasn’t CNN’s leading medical reporter?

My contention is Dr. Gupta as a neurosurgeon obviously has a conflict of interest not to criticize the onslaught of spine surgeries since he and his colleagues greatly profit.

As you know, my complaint is not the first leveled at him. I recall in 2007 when Dr. Gupta stated that Michael Moore's 2007 film Sicko had "fudged facts." Trudy Lieberman, a regular Nation contributor on healthcare and director at the CUNY Graduate School of Journalism, reviewed Gupta's "ineptitude" in reporting on the McCain health plan. As well, his endorsement of Gardasil vaccine without revealing its controversy or CNN’s relationship with Merck also made many question his lack of full disclosure.

Obviously Dr. Gupta, like everyone else, has his own bias in regards to healthcare politics and certainly toward his main professional rivals—chiropractors. But his lack of objectivity as your medical director must be questioned as the evidence shows, especially in matters that concern spine treatment and chiropractic care.

3) The Solution

I urge you to create a plan of restitution for the damage done that would include programming to reveal this exploding spine surgery scandal and to produce a weekly show on complementary and alternative medicine (CAM), which is hugely popular in this country and internationally.

Research by David Eisenberg, MD, from Harvard’s Osher Institute revealed Americans were seeking non-drug, non-surgical solutions and made more visits to complementary and alternative (CAM) providers than MDs. Baby Boomers made 427 million office visits to non-MDs in 1990 compared to 388 million visits to MDs; the follow-up survey in 1997 revealed that the numbers to non-MDs rose to 629 million while the numbers to MDs went down to 386 million.[44]

Dr. Eisenberg noted how his own view of chiropractic has changed from his early days to the present. He was taught in medical school that chiropractic was “irrelevant, worthless, a waste of money, and dangerous.” In the 1980s it was “unproven, unorthodox, and unconventional.” After his study showing the huge usage of CAM, he noted that the terminology has changed from “complementary and alternative” in the 1990s, to “integrative” in 2000-05, and “comprehensive” in present-day.[45] Upon seeing the huge number of Americans using CAM practitioners, Dr. Eisenberg concluded, “Maybe ‘alternative’ isn’t so alternative anymore.”[46]

One only has to look at the popularity of Dr. OZ’s show to realize that the country is hungry for sound ideas that work, especially non-drug and non-surgical treatments.

Hopefully my letter finds you with an open mind and receptive to a new idea that may become a popular new health show for CNN that will benefit millions of Americans suffering with back pain and who seek natural cures for other ailments such as heart disease, diabetes, arthritis, and even some types of cancer.

Indeed, there is more to “health” care than drugs and surgery as the medical profession would have people believe. There is a huge resource for CAM information not far from the CNN headquarters residing at Life University in Marietta that would be more than willing to assist in this programming.

As you can see, the boycott of the chiropractic profession and CAM professions is a major neglect by Dr. Gupta and CNN. I have no reason to doubt that CNN wants “programs that are fair, accurate and responsible.” I urge you to consider my proposal to air the new evidence regarding spine care as well as to give CAM options such as chiropractic a fair opportunity to be reviewed.

I hope to hear back from you on this important matter.

Regards,

 

JC Smith, MA, DC

 



[1] JC Smith, The Medical War Against Chiropractors, (2011)

[2] G McAndrews, “Plaintiffs’ Summary of Proofs as an Aid to the Court,” Civil Action No. 76 C 3777, Wilk, (June 25, 1987):17

[3] AGJ Terret, “Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation,” NCMIC Group Inc, West Des Moines, Iowa, (2001)

[4] G Bronfort, M Haas, R Evans, G Kawchuk, and S Dagenais, “Evidence-informed Management of Chronic Low Back Pain with Spinal Manipulation and Mobilization,” Spine 8/1 (January-February 2008):213-25.

[5] JD Cassidy, E Boyle,  P Cote, Y He, S Hogg-Johnson, FL Silver, and SJ Bondy, “Risk of Vertebrobasilar Stroke and Chiropractic Care Results of a Population-Based Case-Control and Case-Crossover Study,” Spine 33/4S, (Feb. 2009):S176–S183.

[6] A Rosner, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic  20/25 (November 30, 2002) 

[7] J Paling www.healthcare speaker.com, 2000.

[8] Paling, ibid.

[9] V Dabbs, W Lauretti. “A Risk Assessment Of Cervical Manipulation Vs NSAIDs For The Treatment Of Neck Pain,” Journal of Manipulative and Physiological Therapeutics 18/8 (1995):530-536.

[10] RA Deyo, DC Cherkin, JD Loesser, SJ Bigos, MA Ciol, “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 74/4 (1992):536-543.

[11] Paling, ibid.

[12] Paling, ibid.

[13] E Ernst “Deaths After Chiropractic: A Review Of Published Cases,” Int J Clin Pract, 64/8 (July 2010):1162–1165

[14] Gueret G, Bourgain JL, Luboinski B., “Sudden death after major head and neck surgery, Curr Opin Otolaryngol Head Neck Surg. 2006 Apr;14(2):89-94.

 

[15] B Starfield, “Is US Health Really the Best in the World?” JAMA 284/4 (July 26, 2000):483-485.

[16] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28 (2003):524-525.

[17] JC Wilson, “Low Back Pain and Sciatica: A Plea for Better Care of the Patient, Chairman's Address,” JAMA, 200/8 (May 22, 1967):705-712.

[18] Ibid.

[19] Transcript of testimony of John McMillan Mennell, M.D., Wilk v AMA transcript pp. 2090-2093.

[20] KB Freedman, J Bernstein, “The Adequacy Of Medical School Education In Musculoskeletal Medicine,” J Bone Joint Surg Am. 80/10 (1998):1421-7

[21] R Buchbinder,  M Staples, D Jolley, “Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain,” Spine, 34/11 (May 2009)  

[22] PB Bishop et al., “The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the International Society for the Study of the Lumbar Spine Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.

[23] SD Boden, DO Davis, TS Dina, NJ Patronas, SW Wiesel, “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects: A Prospective Investigation,” J Bone Joint Surg Am. 72 (1990):403–408.

[24] MC Jensen, MN Brant-Zawadzki, N Obuchowski, MT Modic, D Malkasian, JS Ross, “Magnetic Resonance Imaging Of The Lumbar Spine In People Without Back Pain,” N Engl J Med. 331 (1994):69–73.

[25] RA Deyo and DL Patrick, Hope or Hype:  The Obsession with Medical Advances and the High Cost of False Promises (2002):191.

[26] Deyo and Patrick, ibid.

[27]  M Brandt, Stanford University Medical Center, “MRI Abundance May Lead To Excess In Back Surgery,” (Oct. 14, 2009)

[28] JD Baras and LC Baker, “Magnetic Resonance Imaging And Low Back Pain Care For Medicare Patients,” Health Aff (Millwood) 28/6 (2009):1133–40.

[29] G Waddell and OB Allan, “A Historical Perspective On Low Back Pain And Disability, “Acta Orthop Scand 60 (suppl 234), (1989)

[30] Bigos et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14: Acute Low Back Problems in Adults AHCPR Publication No. 95-0642, (December 1994)

[31] Freeman MD and Mayer JM, NASS Contemporary Concepts in Spine Care: Spinal Manipulation Therapy For Acute Low Back Pain, The Spine Journal  2010 October; 10 (10):918-940

[32] Chou R, et al., Diagnosis and Treatment of Low Back Pain:  A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society, Low Back Pain Guidelines Panel, Annals of Internal Medicine 2007 October 2; 147  (7):478-491

[33]Milliman Care Guidelines for Lumbar Fusions, Low Back Pain and Lumbar Spine Conditions—Referral Management, www.allmedmd.com

[34] http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/lumbar_spine_fusion_surgery.pdf

[35]John Carreyrou, “Senators Look Into Medtronic, Doctors,” WSJ, June 23, 2011.

[36] Peter Waldman and David Armstrong, “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies” Bloomberg News, Dec. 30, 2010.

[37] John Carreyrou and Tom McGinty, “Top Spine Surgeons Reap Royalties, Medicare Bounty,” Wall St. Journal, Dec. 20, 2010

[38] The Gallup Organization, Democratic Characteristics of Users of Chiropractic Services (Princeton, NJ:  The Gallup Organization (1991)

[39] Chiropractic Care Study, Senate Report 110-335 accompanying the National Defense Authorization Act for FY 2009; letter sent to Congressmen by Ellen P. Embrey, Deputy Assistant Secretary of Defense (September 22, 2009):2.

[40] “Relief for Aching Backs:  Hands-on Therapies were Top Rated by 14,000 Consumers,” Consumer Report (May 2009)

[41] Bigos et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14: Acute Low Back Problems in Adults AHCPR Publication No. 95-0642, (December 1994)

[42] P Manga, D Angus, C Papadopoulos, W Swan, “The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain,” (funded by the Ontario Ministry of Health) (August, 1993):104

[43] The National Institute for Clinical Excellence (UK-NICE) 2009

 

[44] DM Eisenberg, RC Kessler, C Foster, FE Norlock, DR Calkins, TL Delbanco, “Unconventional  Medicine In The United States--Prevalence, Costs, And Patterns Of Use,” N Engl J Med 328 (1993):246-252.

[45] DM Eisenberg, “Practicing within Mainstream Healthcare,” seminar held at the Massachusetts Medical Society headquarters, Boston, Nov. 18, 2006.

[46] Ibid.

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