Articles by JCS
Sincere Contrition or
JC Smith, MA, DC
Perhaps with the upcoming election and the great likelihood of our first black president, the AMA’s House of Delegates has announced a formal apology for its historical racism toward African American medical doctors. (“AMA apologizes to black doctors for past racism,” by Lindsey Tanner, AP Medical Writer Thu July 10).
While the AMA is handing out apologies, methinks the chiropractic profession is due one too. Certainly black MDs were forced to sit in the back of the medical bus for too long, but chiropractors were thrown under the same bus.
Has the AMA HOD had a ‘coming to Jesus’ epiphany to repent for its past transgressions? Indeed, will the AMA be as forthcoming about its genocidal campaign against the chiropractic profession? Okay, stop laughing.
This act of contrition toward black MDs should be seen as nothing more than a politically expedient PR ploy for the AMA since more evidence of its ongoing supremacist attitude was recently displayed again with the AMA’s resolution to restrict the title “Doctor” to apply only to physicians (MDs and DOs) licensed to practice medicine in all its branches, as well as dentists and podiatrists. Obviously the medical good ol’ boy network remains as egalitarian as the Augusta National Golf Club—chiropractors, psychologists, homeopaths, naturopaths, or nutritionists need not apply. After all, there are “right” ways to get well and “wrong” ways as dictated by the AMA.
Without a doubt, the chiropractic profession still has a few bones to pick with the AMA before its public image is absolved of discrimination. The history books will ignore the fact that chiropractors were jailed over 15,000 times in the first half of the last century for allegedly practicing medicine, although licensed chiropractors never hid the fact their care never used drugs and surgery. Indeed, the chiropractors’ crime was getting people well without drugs or surgery.
Nor will most historians teach that the AMA was found guilty of antitrust laws in its anti-competitive and public denigration of its foremost competition, the chiropractors. Reminiscent of Nazi Germany’s policy toward the Jews, in 1963 the AMA Committee on Quackery was established by its Board of Trustees for the sole purpose "to study the chiropractic problem." H Doyle Taylor, who had served ten years on the AMA’s Department of Investigation, was appointed the Secretary of the Committee. In a memo to the AMA Board of Trustees, Taylor wrote, “Your Committee has considered its prime mission to be the first containment of Chiropractic and ultimately the elimination of Chiropractic.”
Few Americans today are aware of the AMA organized a formal boycott of the chiropractic profession to eventually “see them wither on the vine.” The AMA’s supremacists also referred to chiropractors as “killers and rapid dogs.” Even ethical MDs who referred to DCs were threatened with the loss of licensure and ostracized from the medical fraternity for consulting with “cultists and quacks.”
The fact is the AMA funded an organized campaign to thwart any competitors in the marketplace. The AMA used its Department of Investigation to hunt out quackery from 1906 until 1975. In its sixty-nine years, the DOI went after a lot of "enemies" of the AMA, such as those who would threaten their profits or the profits of the closely aligned pharmaceutical interests. Under the guise of “patient safety,” the AMA conducted an illegal campaign to eliminate competitors to their medical monopoly and chiropractors were the main target. The only problem the AMA goon squad eventually faced in court was its inability to prove chiropractors were unsafe in its patient care defense.
In October 1976, led by attorney George McAndrews, plaintiffs Chester A. Wilk, James W. Bryden, Patricia A. Arthur, and Michael D. Pedigo, all licensed chiropractors, filed suit against the AMA in the Northern District Court of Illinois. Other defendants in the suit include the American Hospital Association, the American College of Radiology, the American College of Physicians, and the Joint Commission on Accreditation of Hospitals; in all 16 groups or individuals were named. The suit claimed that the defendants had participated for years in an illegal conspiracy to destroy chiropractic.
After 11 years, on September 25, 1987, Judge Getzendanner issued her opinion that the AMA had violated Section 1 of the Sherman Act (Wilk v. American Medical Ass'n, 671 F. Supp. 1465, N.D. Ill. 1987). Judge Getzendanner ruled that the AMA and its officials were guilty, as charged, of attempting to eliminate the chiropractic profession with a “lengthy, systematic, successful and unlawful boycott” designed to restrict cooperation between MDs and chiropractors in order to eliminate the profession of chiropractic as a competitor in the United States health care system.
The Court ordered a permanent injunction order against the AMA:
“…Although the conspiracy ended in 1980, there are lingering effects of the illegal boycott and conspiracy which require an injunction. Some medical physicians’ individual decisions on whether or not to professionally associate with chiropractors are still affected by the boycott. The injury to chiropractors’ reputations which resulted from the boycott have not been repaired. Chiropractors suffer current economic injury as a result of the boycott. The AMA has never affirmatively acknowledged that there are and should be no collective impediments to professional association and cooperation between chiropractors and medical physicians, except as provided by law. Instead, the AMA has consistently argued that its conduct has not violated the antitrust laws…An injunction is necessary to assure that the AMA does not interfere with the right of a physician, hospital, or other institution to make an individual decision on the question of professional association...”
During the proceedings it was shown that the AMA attempted to:
In order to defend its anti-competitive policy, the AMA’s defense focused on the issue of “patient care,” to which Judge Getzendanner opined:
“The plaintiffs, however, point out that the anecdotal evidence in the record favors chiropractors. The patients who testified were helped by chiropractors and not by medical physicians. Dr. Per Freitag, a medical physician who associates with chiropractors, has observed that patients in one hospital who receive chiropractic treatment are released sooner than patients in another hospital in which he is on staff which does not allow chiropractors. Dr. John McMillan Mennell, M.D. testified in favor of chiropractic. Even the defendants' economic witness, Mr. Lynk, assumed that chiropractors outperformed medical physicians in the treatment of certain conditions and he believed that was a reasonable assumption. The defendants have offered some evidence as to the unscientific nature of chiropractic…But most of the defense witnesses, surprisingly, appeared to be testifying for the plaintiffs. Taking into account all of the evidence, I conclude only that the AMA has failed to meet its burden on the issue of whether its concern for the scientific method in support of the boycott of the entire chiropractic profession was objectively reasonable throughout the entire period of the boycott.”
Despite the legal victory by the chiropractors in this antitrust lawsuit, the covert boycott of chiropractors continued, resulting in a Permanent Injunction order against the AMA by federal District Judge Susan Getzendanner under Section 16 of the Clayton Act to prevent such future behavior. I daresay this injunction has had little impact on the continued covert boycott today.
The anti-competitive effects of the boycott were generally conceded by the defendants' expert, William J. Lynk of Lexecon, Inc. Some of the anti-competitive effects acknowledged by Mr. Lynk included the following:
According to the Court:
“The anti -competitive effects of the AMA boycott were established by defendant's witnesses: The activities of the AMA undoubtedly have injured the reputation of chiropractors generally. This kind of injury more likely than not was sustained by the four plaintiffs. In my judgment, this injury continues to the present time and likely continues to adversely affect the plaintiffs. The AMA has never made any attempt to publicly repair the damage the boycott did to chiropractors' reputations.” (Opinion pp. 10).
Not only did the testimony by defendants’ own witnesses hurt the AMA’s case, but deposition of Dr. John C. Wilson, former Director of the American Academy of Orthopedic Surgery, illustrated dramatically the mindset of these medical supremacists.
Plaintiffs’ attorney George McAndrews conducted this alarming deposition:
Q: Is it possible to manually move a spinal joint through a range of motion?
A: I simply cannot answer your question in that context.
Q: Can you answer the question in any context including your own?
A: No, because this is not a frame of reference in which medical doctors think, and we don’t relate to turning spinal joints around through manipulation. That is the chiropractic concept, and we don’t understand it. We don’t relate to it. We don’t know what you are talking about.
Q: Have you ever done any research into that?
A: No. And I don’t have any desire to do any research into that or any other cult.
Q: I am not really talking about cults now. I am talking about the manual manipulation of spinal joints.
A: No. I have no interest in or desire to pursue the manipulation of spinal joints as a theory.
A: Because I don’t believe in this kind of thing. I don’t know of any scientific basis that would cause me to pursue this as a way to help people.
Not only is Dr. Wilson’s closed mind shocking, but it clearly revealed his supremacist attitude as well as his blind eye toward manual medicine. Indeed, how can any spine specialist ignore the 137 joints in the spine and the role of joint dysfunction may play in spinal pain? Indeed, who’s being anti-scientific now?
This medical myopia to ignore joint dysfunction is not only anti-scientific, it is harmful considering the millions of people suffering with back pain who are subjected to unnecessary drugs, shots and surgery that have proven ineffective in most cases. RCTs comparing conservative care to spine surgery show there is no appreciable advantage to surgery in the long term. Nonetheless, the medical myopia continues today to harm back pain patients who would benefit from manipulative therapy.
In another deposition, Dr. John McMillan Mennell, orthopedist, testified as follows about the lack of education and training medical students receive in medical school on the musculoskeletal system:
Q: At the medical schools with which you are familiar, do you know about the educational program in the musculoskeletal pain area for medical students?
A: Usually it is anything between zero to four or five.
A: Yes, in four years.
Aside from the inherent antipathy toward manipulative therapy by medical doctors, another obstacle in the study of spinal mechanics is the added length of time required. In 1979, the Royal Commission of Inquiry on Chiropractic in New Zealand, following an 18-month study, mentioned:
“The Commission accepts the evidence of Dr. Haldeman, and holds, that in order to acquire a degree of diagnostic and manual skill sufficient to match chiropractic standards, a medical graduate would require up to 12 months full-time training, while a physiotherapist would require longer than that.”
Dr. Mennell elaborated on the role of joint function in LBP:
“The science of mechanics demands that joint play movement is prerequisite to normal pain-free functioning of movement …in the spine there are about 137 synovial joints between the lamina facets, the occipital condyles, the bottom of the skull as it rests on the atlas, the sacroiliac joints, the sacrococcygeal joints, the z-joints, even the joints of the fundusca in the neck.
“When you are dealing with manipulative therapy in the spine…your objective is to try to restore the proper motion joint play, which is prerequisite to the normal function in the spine…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.”
Incredibly, the average general medical practitioner receives only 4 hours of training in the musculoskeletal system, yet purports to be qualified to diagnose and treat these conditions. The recent Peul et al. study comparing conservative care to microdiscectomy for sciatica had the gall to use general practitioners as the conservative care practitioners instead of chiropractors. Rather than using the best in conservative care—SMT, flexion/distraction, and non-surgical spinal decompression—these GP’s care consisted of cheap advice and pain pills. Even while avoiding the best of conservative care, the results were eye-opening in that at 6 months there was no advantage among the surgery patients.
Considering 85% of adults will suffer from an acute bout of low back pain, this medical lack of education leads to mismanagement—misdiagnosis, mistreatment, and misinformation. No doubt this is an underlying cause of this pandemic of pain costing billions annually. Outpatient visits accounted for $30.8 billion from medical imaging, diagnostic tests, spinal injections and spinal fusion surgery. One can only imagine the cost savings if DCs were used instead of GPs and surgeons to manage this epidemic.
Appeals, FTC & Supreme Decisions
After Judge Getzendanner’s verdict, the AMA was in store for more setbacks. The district court's decision was affirmed by the U.S. Court of Appeals on February 7, 1990 (Wilk v. American Medical Assn, 895 F.2d 352, 7th Cir. 1990). The AMA petitioned the U.S. Supreme Court three times, but each time the Court denied certiorari.
The Court grants certiorari only when a case presents a novel question of law and the Wilk case was a straightforward application of the Sherman Act.
Before 1980, Principle 3 of the AMA Principles of medical ethics stated: "A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily professionally associate with anyone who violates this principle." The AMA eliminated Principle 3 in 1980 during a major revision of ethical rules (while the Wilk litigation was in progress). Its replacement stated that a physician "shall be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services."
Not only did the chiropractors cry foul against the AMA’s antitrust activity to eliminate competitors, but in 1981 the FTC also brought suit against the AMA. The Federal Trade Commission had found that the AMA’s actions had created problems in the treatments for patients, which it called “a formidable impediment to competition in the delivery of health care services by physicians in this country.”
“That barrier has served to deprive consumers of the free flow of information about the availability of health care services, to deter the offering of innovative forms of health care and to stifle the rise of almost every type of health care delivery that could potentially pose a threat to the income of fee-for-service physicians in private practice. The costs to the public in terms of less expensive or even, perhaps more improved forms of medical services are great.”
In support of the FTC, the Justice Department argued that the AMA ignored the law in the past.
“In fact, petitioners’ (AMA’s) long history of illegal behavior strongly supports the need for a remedy to reverse the effects of the restraints of trade they have imposed. And although petitioners are now quick to admit that their past conduct was unlawful, they have not been so quick to mitigate the effects of their past violations. The Commission’s remedial order does what petitioners themselves have been unwilling to do. It dissipates the effects of past violations and protects the public against their repetition.”
The AMA now permits medical doctors to refer patients to doctors of chiropractic for manipulative therapy if the medical doctor believes it is in the best interests of the patients, but the former overt discrimination simply remains a covert effort of non-cooperation that still lingers on today—few hospitals allow DCs on staff, few MDs regularly refer patients to DCs, and medically-controlled organizations like Workers’ Comp still marginalize chiropractic care despite low back pain is a leading on-the-job injury.
The AMA’s accusation that chiropractic was an “unscientific cult” heralded an era of many international studies and guidelines on the epidemic of low back brain. Just 7 years after the end of the Wilk Trial, the Agency for Health Care Policy and Research (AHCPR) made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for low back pain. Ironically, these studies have shown that manipulative therapy is a “proven method” whereas the medical model of drugs, shots and surgery have failed the same scrutiny—conclusions that the AMA couldn’t stomach.
In 1994, the Agency for Health Care Policy and Research (AHCPR), an agency of the U.S. Department of Health and Human Services, issued a 170-page study titled Acute Low Back Problems in Adults, along with an accompanying 30-page "Quick Reference Guide for Clinicians" titled Acute Low Back Problems in Adults: Assessment and Treatment. The study was conducted by a multidisciplinary panel comprised of 12 medical physician experts, and other health care professionals and consumer representatives, who were brought together by the AHCPR to perform an evidence-based analysis of all research trials on all treatment approaches to acute low back pain in adults. Abstracts of more than 10,000 research papers were reviewed, and almost 4,000 articles were retrieved.
These evidence-based guidelines for acute low back pain developed by AHCPR concluded that spinal manipulation hastens recovery from acute low back pain and recommended that this therapy be used in combination with or as an alternative to nonsteroidal anti-inflammatory drugs. At the same time, AHCPR concluded that various traditional methods, such as bed rest, traction, and other physical and pharmaceutical therapies were less effective than spinal manipulation and cautioned against lumbar surgery except in the most severe cases. Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement. It also concluded that for acute low back pain not caused by fracture, tumor, infection, or cauda equina syndrome, spinal manipulation is the treatment of choice.
After the release of AHCPR the power of political medicine unleashed its wrath. The North American Spine Society successfully lobbied Congress to revoke the ability of the Agency on Health Care Policy and Research to do its job mandated by Congress to investigate medical procedures and to recommend treatment guidelines with the goal to lower costs and improve outcomes.
The acute LBP guideline was the 14th done by AHCPR and it’s noteworthy that the first 13 guidelines did not suffer the same wrath. The medical ire stemmed from the criticism levied at spinal fusions, especially those involving pedicle screws due to the findings that fusions had few scientifically validated indications and was associated with higher costs and complications rates than other types of back surgery.
NASS formed a so-called grassroots movement dubbed “Center for Patient Advocacy” to make it appear its objections were from consumers, not special interests. A manufacturer of pedicle screws, Sofamor Danek, unsuccessfully sought a court injunction to prevent publication of the AHCPR guideline on acute low back pain.
Not only were they successful in gutting the AHCPR, these angry orthopedists even sued the researchers involved to discourage any other attempts to change the medical status quo. As a member of the AHCPR panel, Dr. Richard Deyo subsequently co-authored in The New England Journal of Medicine an article in response to this intimidation, "The Messenger Under Attack--Intimidation of Researchers by Special Interest Groups."
He alluded that the for-profit mindset of some surgeons supersedes the value of research:
"The huge financial implications of many research studies invite vigorous attack... Intimidation of investigators and funding agencies by powerful constituencies may inhibit important research on health risks and rational approaches to cost-effective health care.”
“Don’t confuse us with the facts.”
Other international studies have confirmed that manual therapy is an effective treatment:
Adherence to these practice guidelines could substantially increase the numbers of patients referred for spinal manipulation. Sadly, despite the numerous international guideline recommendations, the number of back surgeries has increased substantially while referrals to DCs have not increased as one might expect in this era of evidence-based healthcare. In fact, the numbers of patients seeking chiropractic care has dropped from 10% to 7% over the last decade despite these recommendations. Could this be another lingering example of the covert medical boycott?
Scott Haldeman DC, MD, PhD and Simon Dagenais DC, PhD, commented on the BJD study on chronic LBP, “What have we learned about the evidence-informed management of chronic low back pain?”
“Although potentially heartening to the many clinicians who have adopted aspects of this approach, it is somewhat disappointing to note that 14 years after [AHCPR] dozens of highly promoted new interventions, thousand of studies, millions of lost work days, and billions of dollars spent on its care, so little has changed in the evidence available to guide stakeholders and support treatments for CLBP.”
Just as NASS and many in the medical profession turned a blind eye to the AHCPR recommendations and to the many European studies on LBP, the same closed attitude will meet the BJD recommendations on chronic LBP. Undoubtedly both Deyo and Haldeman must feel frustrated on this medical intransigence. All I can say is welcome to the world of medical supremacists whose motto is, “Don’t confuse us with the facts.”
Although the AMA’s racism against its own black members may be on the wane, the genocidal war against the chiropractic profession continues with the covert medical boycott of chiropractic care. It appears the AMA has not learned its ethical and legal lesson to allow free trade on a level playing field without restraints.
For too long chiropractors have been ignored, marginalized, and their methods have been deemed “experimental and unproven” despite the good clinical results. Even when recent RCTs and international guidelines recommend manual medicine for spinal disorders, it is given short shrift by those who suffer from a professional prejudice.
Paul Goodley, orthopedic physician, author of Release from Pain, and long-time promoter of manual medicine, coined a term, Fundamental Flaw, concerning the antipathy of mainstream medicine to manual medicine that he contends as led to a pandemic of pain. I might add it has also led to a pandemic of unnecessary drugs, shots, MRIs, spine surgery and skewed research.
“Eventually, the prejudice against manipulation self-perpetuated and evidence was always available to justify this attitude. There have always been [chiropractic] charlatans. So, instead of the manipulative fundamental dynamically developing as a cohesive, trustworthy guide within traditional medicine, it was discredited as the synonymous derelict symbol of its most despised competitor - chiropractic.”
Sadly, evidence-based research and guidelines seem to be ignored by the powers-to-be, and much of this disdain is due to the Fundamental Flaw. While researchers may acknowledge the value of SMT, flexion-distraction, and non-surgical spinal decompression, they also have trouble admitting those damn chiropractors may be right.
This dilemma—the conflict between research and the imagery of DCs—remains a paramount issue that we DCs must deal with now.
George Lundberg, MD, Medscape Editor in Chief and former editor-in-chief of JAMA, once told me in private communication:
“If some influential individual or group in chiropractic would follow your thesis, and would loudly and openly embrace EBM, let the chips fall where they may, and, if I may push further, openly repudiate the ‘vertebral subluxation and resulting nerve pressure is the root of all diseases’ (presumably the Palmer belief structure),
…then I and many other physicians could openly and without fear and derision look at what 2005 EBM chiropractors actually do and go forward together.”
I accept Dr. Lundberg’s challenge wholeheartedly to let the chips fall where they may in regards to manual medicine for spinal disorders, principally LBP. But will the AMA be as open to do the same and accept this challenge? Will the AMA finally admit there is great value to manipulative therapy?
Conversely, will the ACA “openly repudiate” the chirovangelism long associated with Palmer chiropracTIC? This is the biggest hurdle for our profession—to admit some DCs have gone too far because of their vitalistic beliefs that remain unproven to this day—but still held close to the hearts of many. Ringing in the ears of many are the infamous words of Big $id Williams, “The only thing chiropracTIC can’t cure is rigor mortis.”
On the other hand, just as no religion should be made to apologize for its beliefs, should a healthcare profession feel the same? Should the chiropractic profession separate its science/treatments from its vitalistic philosophy, just as America has separated its church from state affairs in government? If the Palmer tenets are the only stumbling block to cooperation with the medical mainstream, should we go down fighting or reframe our position in order to survive? This question must be answered now if we are to move forward.
Conclusion: AMA Ober Alles
Until the AMA publicly apologizes to the chiropractic profession for its professional pogrom, it should still be considered a bastion of medical supremacists with discriminatory attitudes and an antitrust agenda that restricts proper healthcare cooperation with chiropractors for the betterment of patients.
The apology to black medical doctors is too little too late, albeit a nice gesture. Indeed, apologizing to its own black members is one thing, but until the AMA ceases and desists with its bigoted attitude toward other healing arts, the public and media should still regard the AMA as a supremacist organization whose main goal is to enrich its own trade members by restraint of trade and certainly not to enrich the health of all Americans by using whatever healing method is best.
Dr. Benjamin Rush, Founding Father, Signer of the Declaration of Independence, and the Father of American Psychiatry, supposedly warned of the rise of a medical monopoly:
“Unless we put medical freedoms into the Constitution, the time will come when medicine will organize into an undercover dictatorship. . . . All such laws are un-American and despotic and have no place in a republic. . . . The Constitution of this republic should make special privilege for medical freedom as well as religious freedom.”
I urge the AMA to extend its contrition to all licensed health professionals who share the goal to help sick people get well. I also urge the AMA to promote medical freedom and to stop interfering with other healing arts as Dr. Rush allegedly said.
Indeed, no one health association holds the key to every aspect of healthcare, and in this epidemic of back pain, escalating costs, and evidence-based research and guidelines showing the efficacy of manual manipulation, it would do every American well for the AMA to end its covert campaign to boycott chiropractic care and give patients the best care from all worlds.
[Thanks to the late chiropractic historian Joe Keating, FCER, Wikipedia, and George McAndrews for help on this episode in our history.]