Articles by JCS

Confronting Iatrogenesis

Confronting Iatrogenesis

By

JCS

While a student in chiropractic college listening to the incessant ranting about chiropractic catechism and the religion of Innate (which seemed more fiction than fact), I realized that if I were to understand the state of the profession, I had to virtually educate myself on these matters. It was obvious the administration cared less about the political status of chiropractic or the politics of healthcare. To them, so-called "philosophy" and upper cervical adjustments were all we students needed to know—a pop and a prayer to Innate—and that’s exactly what we got and nothing more.

While doing research in their skimpy library, I found an interesting book by Ivan Illich, The Medical Nemesis, in which he coined a few terms that piqued my interest. We all know that "iatrogenesis" means physician-induced problems. "Clinical" iatrogenesis for chiropractors usually consists of broken ribs, occasional strokes or supposed disc aggravation, to name but a few. Of course, the rate of accidents is 1-2 per million for all SMT and, excluding the 40% of problems caused by the 6% of non-DCs who do manipulation, this rate actually drops to 1 in 3 million for CMT. Considering the rate for cervical surgery is 15,600 accidents per million, I can live with our very low rates.

Social Iatrogenesis: How the Healthcare System Makes You Sick
Illich also coined a couple of new terms which have haunted me for over twenty years now. He discussed the concept of "social" iatrogenesis in which social health systems made people sick or caused more problems. We DCs can easily relate to this when we see MCOs and group health insurance exclude chiropractic care, forcing patients into the medical world of drugs and surgery. Also, when PI attorneys prefer sending MVA patients to surgeons in order to increase their payoffs, the "system" is the culprit. When hospitals exclude SMT because they can make more money by doing surgery instead, the "system" is to blame. When a workers’ comp patient relates to me that her claim adjuster says "Chiropractors are no-nos" and "they do more harm than good," something is terribly amiss. In these cases, the "system" is making patients suffer more due to their discriminatory policies toward chiropractors.

Dr. Pran Manga’s latest paper on chiropractic discussed how increasing patient access to chiropractic care would save money and better help patients, thus preventing social iatrogenesis. I might add that in Canada, they operate in a not-for-profit setting, which drastically changes their motivation to discover what methods work best, not necessarily which methods make the most profit.

“In order for the Ministry of Health to maximize the savings in health care costs, it should maximize the flow of patients to chiropractors for NMS conditions and injuries." (Discussion Paper by Pran Manga and Doug Angus)
Obviously railroading patients into the drug ‘em, cut ‘em medical model has only been successful in making surgeons very wealthy at the expense of patients’ well-being. "Social" iatrogenesis not only denies patients’ their freedom of choice concerning their own bodies and health care providers, it denies DCs their right to compete on a level playing field.

Cultural Iatrogenesis: The Ugly American
Illich also coined another phrase that hits at the core of our nation’s healthcare disaster—"cultural" iatrogenesis. In this instance, he noted how bad habits and attitudes made people sick. The junk phood epidemic and tobacco addiction are good examples of this. The reliance upon medications, the proverbial "wonder" drugs, also has contributed to a demise in Americans’ health. Is it really a wonder why Americans lead the world in every category of chronic degenerative diseases when you consider our lifestyle?

As chiropractors, we still face cultural attitudes that go unresolved, such as the medical slander that still exists. The fact that our profession has not successfully initiated a PR program to counteract the decades of propaganda has allowed these misconceptions to continue unabated. In this case, patients are becoming ill not because of clinical mistakes or system bias, but due to prevailing unhealthy attitudes in our society.

In regards to proper spinal care, it’s painfully obvious that 90% of Americans don’t know how to manage their backs. Plus, we have the medical society pushing their useless drugs or their back surgeries to no avail. Despite the AHCPR guideline which recommends SMT and discounts the entire medical approach of physical therapy, drugs and surgery, nonetheless the "slipped disc" or "pulled muscle" paradigm remains paramount in the public’s mind despite MRI research that disproves the disc theory.

Until they learn you don’t slip discs, but you do slip spinal joints, the medical model will remain the source of cultural iatrogenesis. As the famous Rene Cailliet, MD and noted author, recently wrote in the American Journal of Clinical Chiropractic, "With all these [LBP therapies] and many more being used, it is apparent that most are not, per se, effective." Finally, an honest MD admitting the ineffectiveness of medical methods for LBP.

It may take three generations of Americans before this paradigm shift occurs. The research alone won’t change the public’s conception of proper spinal care, as we now can see. Until public consciousness changes, the current political and economic forces of the medical cartel will suppress any research that it fears, such as the AHCPR guideline.

Political Iatrogenesis: Poly Sci of Chiropractic
Let me take leave with Illich’s versions of iatrogenesis and add a few more. Aside from clinical mistakes, systems or cultural causes adding to the demise of American healthcare, we all know the importance of political action in the massive economics of healthcare. Oddly, however, in my twenty plus years in chiropractic, I have never read an article about the "political science" of healthcare or chiropractic. Granted that the ACA’s PAC has done much for our profession, but aside from them, I cannot recall any discussion at any seminar or while in college about the poly sci of chiropractic. (Is it a taboo subject, or what?)Yet we all know our fate rests in political action such as the current HCFA case.

Until legislation is passed that includes chiropractic on equal footing in every health care program, we will remain second-class practitioners. Until we convince the public that they cannot be totally well until their spines are healthy, we will only be backache doctors who they occasionally need. Until we have our own spokespeople pleading our case, our reputation will remain a function of medical bias. And until our message is believed by the public, they will continue to suffer at the hands of the back surgeons.
Dr. Manga addresses this issue in the conclusion of his latest paper when he discusses "distributive justice" in regards to biomedical ethics.

"We are referring to the principle of distributive justice which hardly ever gets mentioned, let alone seriously considered, in studies of health human resources substitution. We would argue that the principle of distributive justice, and a parallel principle of equality of opportunity, require that the government implement all cost-effective substitutions; failure to do so results in unfairness to the taxpayers and unfairness to certain health care professions…. The monopolization of the health care services turf is also inequitable from yet another perspective. It denies some professions equal opportunity to earn income commensurate with their ability, effectiveness and effort…There is an egregious and mocking injustice in the fact that spinal manipulation performed by chiropractors is subject to a high user fee to patients and low OHIP fee to chiropractors, but is free to patients with a high OHIP fee to medical doctors even when it is known that medical doctors are less expert in the art and science of spinal manipulation, and, worse, when they have a significantly higher incidence of adverse health outcomes."

We chiropractors have long known the injustices of being out of the loop—forcing patients into unnecessary back surgery, inhibiting our enterprise on a level playing field, restricting open competition in hospitals and managed care programs, to name but a few of the problems we face. Unfortunately, after riding in the back of the medical bus for decades, it seems too many DCs are comfortable and unwilling to fight for justice—a good illustration is the scab mentality via woefully low membership numbers in our state and national organizations.

Dr. Manga noticed this problem also and mentioned:
"Curiously, the professions that have and still suffer the adverse effects of the inefficient use of our health manpower have not used this argument forcefully enough to encourage and urge the desired reforms. They should." Amen to that!

Financial Iatrogenesis: Perverse Motivations

In the multi-billion dollar back pain industry, how the medical pie is cut is cornerstone to most of our ills. At the COCSA convention recently, Dr. Clem Bezold of the Institute for Alternative Futures acknowledged that "perverse motivations" were at work in our for-profit healthcare system. Only in America does this occur, or so it seems, where hospitals, workers’ compensation and health insurance companies are not concerned about lowering the high costs of health care. In fact, they actually enjoy the rising costs of health care. As we all know, if the payers pay out more, then just charge more in premiums, so there’s more money for everyone. This perverse motivation keeps the money flowing despite the apparent illogic of using less effective and more expensive methods for back pain like surgery.

The reason why DCs aren’t in most hospitals has nothing to do with the lack of scientific proof or clinical ineffectiveness. The meta-analyses done by RAND, Meade, AHCPR, Manga I & II have all concluded that for the majority of LBP, SMT is safer, faster, and cheaper. The issue of science validating SMT is no longer the focus of debate—as Dr. Manga wrote, "The evidence is overpowering."

Now the argument seems to focus on who’s going to control the all mighty billion dollar industry of back pain treatment. And since profit, not clinical results, motivates the healthcare administrators in hospitals and MCOs, they turn a blind eye to research about cost-effectiveness if it means less profit for them.

For example, in the recent edition (vol. 12, No. 2) of Academic Clinical Practice, a featured article about CAM mentioned:
"The applicable question for hospital administrators looking to shore up ever-widening leaks in hospital revenue may not be whether alternative therapies are proven, but whether they will translate into increased revenue. Just as the lack of hard scientific research on alternative medicine has long been cited as a reason to doubt its effectiveness, similar questions now surround its profitability. As yet, there are no clear answers."

According to MetLife Insurance statistics, the average "medical non-surgical back" costs $7,210 and the average "surgical back" costs $13,990. But, according to research from the North Carolina Back Pain Institute, the average chiropractic case costs approximately $800 for the same diagnostic code.[1] Obviously, the reason for excluding chiropractors from hospitals is due simply to this economic decision to make more money from surgery than from SMT. This perverse motivation supercedes research, cost-savings or just doing the right thing for the patients.

Public Relations Iatrogenesis: Medical Propaganda

For the most part, we can’t even get the media’s attention to inform the public about the superiority of SMT over surgery, let alone cast a negative light at the clinical iatrogenesis and high costs this distributive injustice costs the American people. Again, chiropractic’s plight seems to be a non-issue in the media. The recent "Medical Mistakes" series of newspaper articles by the Philadelphia Inquirer may have illustrated medical iatrogenesis, but the writer never dared to tread on the issue of chiropractic being snubbed because it’s too cheap and effective.

Aside from medical misinformation, the chiropractic profession has had little luck with its own PR efforts. The ACA/ICA Alliance for Chiropractic Progress campaign that was heralded as a landmark PR effort was another expensive bust. In 1995 the CCF’s video, Simple Beginnings, was another expensive effort that amounted to nothing, as was the Rose Bowl parade float. Just why our chiropractic leaders can’t find an effective on-going PR program that validates our profession is a mystery to me. And until they do, we will remain the "mystery science" profession whose image is more the results of derogatory exposés of the news media than the good results we all achieve daily in our offices.

In my estimation, until chiropractic deals with each level of iatrogenesis, we will continue to remain outside the loop of popularity. Instead of one-page ads in Prevention magazine, we need national exposure on TV to plead our case--publicity rather than advertising is the key to our success. Until we have a TV chiropractic spokesperson to reposition the public on talk and news shows, the public and media will continue believing the medical misinformation about chiropractic and the best solution to the epidemic of back pain. Indeed, rather than paying big bucks for ineffective ads, let’s promote ourselves via the news with articulate spokespeople, such as the ones I heard speak at the COCSA convention.

Image Iatrogenesis: Shooting Our Own Foot

This term means the proverbial act of chiropractors shooting their image in the foot with their tacky business methods, such as bait-and-switch ads, strip-mall offices, free spinal exams, mall show theatrics and the general second-rate image breakers mostly associated with chiropractors. This also includes the TV exposés showing illegal activities such as insurance fraud, runners, Medicaid scams, to name but a few. As Dr. Pran Manga once mentioned to me, most chiropractors don’t seem overly concerned about their poor image.

"It is clear to me that a thorough and serious review of chiro ethics and professionalism is in order, long overdue in fact...chiros do not rate very high among health care professions for being concerned about professional ethics...I say this as one who teaches and has taught bioethics for 14 years." (private communication, June 17, 1999)

It’s a sad indictment when one of our best advocates is willing to admit to the image iatrogenesis that continues to plague our profession. Just what will it take for the ethical mainstream DCs to "Just say No!" to the charlatans who besmirch our collective image?

Attorney George McAndrews in his speech to the 1998 ACA Convention in Vancouver also mentioned chiropractic's PR dilemma: "5% of you are cultists, 5% of you are freaks, and the rest of you...keep your mouths shut."

I am also curious why too many DCs are apparently resigned to the second-class status of chiropractic in our country’s healthcare systems. We allow unscrupulous, unqualified so-called educators to exploit our students by operating diploma mills aimed at quantity, not quality, as they also deny students freedom of speech and thought. We watch as Scientology seminars brainwash our practitioners with visions of sugar plums from L. Ron Hubbard. We herald the Innatists as so-called "philosophers" when, in fact, they know nothing of real philosophy, instead preaching out-dated dogma as some type of chiropractic catechism.

For the most part, we chiropractors seem to accept cults as a normal part of the profession, we join factions that entrench our differences, and many alienated DCs profess a scab mentality, allthewhile bemoaning our lowly status and disunity. When some of our leaders suggest we unite around our commonalities, everyone nods in agreement as they defend their ideological separatism. Yet little in terms of unity gets done. Indeed, if the original 13 colonies were headed by DCs, there never would have been a United States.

You tell me what the solution is. I’m all ears. But what do I know? I’m just a country chiropractor wondering what it will take to stop the various forms of iatrogenesis in this country, and especially within chiropractic.



[1] Carey, TS et al.  The Outcomes and Costs of Care for Acute Low Back Pain Among Patients Seen by Primary Care Practitioners, Chiropractors and Orthopedic Surgeons.  New England Journal of Medicine.  333 (1995):  913-17.

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