Articles by JCS

Paradox Choosing Wisely

Part Three

The Paradox of Choosing Wisely

I understand the Choosing Wisely program was designed to eliminate waste in medical care, but it quickly became obvious to me this program does not understand there are bigger fish to fry than imaging for LBP.

Nor does this program address the bigger issues such as the massive opioid crisis and the tsunami of unnecessary back surgeries. If Choosing Wisely is carried to its full extent, it will open up a can of worms to embarrass the medical profession; indeed, it is only scratching the surface of reform as it now stands.

The problem isn’t just too many unnecessary images for LBP, which in part I totally agree, but Choosing Wisely should include the bigger problems of too many inept MDs, too many opioids, ESIs, and spine surgeries, and the lack of Informed Consent about alternative choices to medical care.

Indeed, why weren’t these issues included in the Choosing Wisely report if they truly wanted to have patients and MDs choose wisely in order to Do No Harm?

 

Risky Medical Business

First of all, if all health professionals were to use only EBM treatments, the medical profession would be in world of hurt considering in 2013 the BMJ published Clinical Evidence suggesting over half of 3,000 medical treatments is ineffective, unproven or too dangerous to use.

This lack of evidence is most obvious in spine care with the debunked disc premise, the many unproven spine interventions done by Needle Jockeys, and certainly the misuse of opioid painkillers that has led to the Pharmageddon we now face in the Quiet Epidemic of chronic pain leading to mortalities/suicides.

The Washington Post was one of few newspapers reporting this BMJ researchSurprise! We Don’t Know If Half Our Medical Treatments Work.”  Yet we don’t hear the Choosing Wisely advocates telling the public to beware of the thousands of risky procedures and deadly drugs in the medical profession, which would do wonders to Do No Harm.

Another study by the British Medical Journal revealed in 2016 medical care was the third-leading cause of death in the United States in the range of 251,000 per year (an admittedly conservative estimate) that still equates to 700 deaths per day due to medical mistakes. Again, how can patients choose wisely if they are not told of the deadly risks of medical care?

Obviously there is room for improvement in the medical profession that transcends this Choosing Wisely report. While the intent is good, it ignores the bigger issues in healthcare.

Misleading Cautionary Tale

In a new report: First, Do No Harm, Calculating Health Care Waste in Washington State, February 2018, again the issue of waste for low back imaging was a primary concern based on erroneous assumptions. This report still plays on the fear of radiation as the primary reason to stop all imaging, a point disproven by many researchers.

Let me point out in blue text a few mistakes in the logic of this manifesto.

Imaging for low back pain

This measure is based on Choosing Wisely recommendations from the American Academy of Family Physicians, the American Society of Anesthesiologists – Pain Management, the American Academy of Physical Medicine and Rehabilitation, and the American Chiropractic Association.

Back pain is among the most common medical conditions and is one of the top reasons for adult visits to physicians. Most adults experience low back pain at least once in their lifetime. It can be quite painful and can limit physical activity. The evaluation of low back pain by a medical provider should include a complete, focused medical history looking for “red flags,” which include (but are not limited to) severe or progressive neurologic problems, fever, trauma and indications of a serious underlying problem (e.g., malignancy). [No mention whatsoever of subluxation/spinal alignment issues] In the absence of these “red flags,” there is strong evidence that most patients recover from low back pain within six weeks and that imaging of the lumbar spine before six weeks does not improve outcomes for the patient [Perhaps depending what is done]. In fact, clinical experts agree that the potential harm associated with premature imaging in patients with low back pain [to the contrary not all experts agree; in my previous article, Chiro Civil War, I cited the following studies refuting the radiation fear mongering:   Radiation Study Finds Little Risk; A Rebuttal to Chiropractic Radiologists’ View of the 50-year-old, Linear-No-Threshold Radiation Risk Model; Subjecting Radiologic Imaging to the Linear No-Threshold Hypothesis:  A  Non  Sequitur of Non-Trivial Proportion;   Is Diagnostic Medical Radiation Safe?] outweighs the benefits imaging can reveal anatomic abnormalities [such as bad discs, arthritis, incidentalomas] that are unassociated with the pain-–but the identification of the abnormalities can lead to unnecessary treatment, including additional imaging and surgery, driving up costs and increasing the risk of harm to patients. [Yes! Do I hear a halleluiah?]

This measure identifies use of imaging (X-ray, CT and MRI) in patients with low back pain within 42 days of a diagnosis of low back pain as wasteful [in the medical model, that is.]

Only the costs of imaging and professional fees for radiology are included in this measure.

I agree too many images are taken by medical providers looking for the rare “incidentalomas” such as “bad discs” and the “red flags” of pathoanatomical disorders (cancer, fractures, infections, cauda equina) found in ~10% of cases “that are unassociated with the pain” but “can lead to unnecessary treatment, including additional imaging and surgery, driving up costs and increasing the risk of harm to patients” as the report mentioned.

Spot on! But it would have been more important if this report had explained why “incidentalomas” are unassociated with pain. They walked right up to the elephant in the room but again avoided seeing it.

Richard Deyo, MD, MPH, co-author of Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises, also agrees that “many of these disc abnormalities are trivial, harmless, and irrelevant, so they have been dubbed incidentalomas,” equivalent to “finding gray hair” since, he contends, both are part of the normal aging process.[1]

This is the most important observation in this report; the real issue is not too much radiation from xrays (although CT scans are notorious), but the bigger problem is the medical misinterpretation of imaging to convince patients into back surgery on the disproven grounds of ‘bad discs’.

The Big Difference

Aside from red flags, chiropractors also diagnose for subluxations and structural patterns to determine a clinical protocol to choose our treatments wisely rather than blindly guessing where to adjust. (Footnote: of course, I am speaking about those evidence-based DCs who are specific in their treatments rather than the “pop and pray” chiropractors and physical therapists who blindly manipulate patients without the use of imaging. As long as they hear a pop, they’re satisfied.)

This difference is the gist in this issue—MDs looking for incidentalomas and rare pathoanatomical red flags vs. DCs looking for mechanical/structural pathophysiological issues and subluxations. It’s really a matter of orientation as to the actual cause of back pain—‘bad discs’ vs. joint dysfunction/subluxation.

This difference remains a dilemma to the millions of patients with spine-related disorders—they simply do not understand the commonplace incidentalomas may have nothing to do with their pain.

Consequently they cannot choose wisely when their MD ignores joint dysfunction or subluxation as a major cause of their ailment and only recommends spine fusion based on an image showing a ‘bad disc’.

Unbeknownst to patients, research confirms the role of joints in back pain and the value of manipulation and “hands-on” therapy. Two studies led by Donald Murphy DC, DACAN, found joint dysfunction was the cause of neck pain in 69 percent of cases and the cause of low back pain (lumbar and sacroiliac) in 50 percent of patients.[2],[3]

Dr. Murphy explained the relationship between pathoanatomy and pathophysiology:

“Pathoanatomy only creates the potential for pain. Physiology is what determines whether pain actually occurs or not, and psychology determines how much suffering results from that pain.”[4]

A 2006 study on lumbar spinal stenosis also led by Dr. Murphy and Eric L. Hurwitz, DC, found patients treated with manipulative therapy had an astounding self-rated improvement of 75 percent overall.[5] Dr. Murphy is now involved with the Primary Spine Provider Network to train DCs and PTs to be primary spine providers inasmuch as medical primary providers are woefully ill-trained in MSDs.[6]

Not only did Dr. Murphy’s study support the use of spinal manipulative therapy for spinal stenosis, it also proves another point in the argument of physiology versus anatomy.

Despite a 75 percent success rate for pain control, these patients afterwards still had the pathoanatomy of spinal stenosis, just as patients with degenerative disc disease who improved with chiropractic care still have ‘bad discs’ afterwards. What improved was the functioning of spinal mechanics while the pathoanatomy remained the same.

I asked Dr. Murphy to address this paradox:

“Bingo, JC. Clearly the pathoanatomy did not change. We have this discussion frequently in the neurosurgery department when I make the point that the spine is capable of handling pathoanatomy as long as the physiology is right (and psychology, of course). [7] 

Dr. Murphy admits another problem in spine care is the prevailing medical bias against chiropractors:

Many patients are told not to go to a chiropractor, told that their spine is degenerated and the last thing they want to do is to have someone move it. In my experience, having someone move the spine is the best thing.

“The advantage we have as nonsurgical spine specialists is when it’s not clear whether a person will respond or not, there’s no harm in giving it a try. The worst thing that can happen is that they don’t respond. With surgery, if you’re not sure whether the person is going to respond or not, it’s a lot harder to just say, ‘Let’s go for it and see what happens.’ You’re making a permanent change in the structure of the spine.” [8] 

The primary importance of physiology in the spine explains why the diagnosis of ‘bad discs’ was cleverly deemed a “red herring”[9] by Dr. Murphy, similar to Dr. Deyo’s term “incidentaloma.”

So why aren’t medical patients told of this paradox?

Simply because ‘bad discs’ are used by MDs as a sales pitch to convince naïve patients these “incidentalomas” are significant when, in fact, they may actually be ‘coincidentalomas’ with undiagnosed joint dysfunction at the same level. Indeed, discs don’t herniate or degenerate for no reason.

Bad Discs = Bad Surgeries

Another point MDs fail to inform patients in order to choose wisely concerns the comparative research shows the failure of spine fusions.

In 2010, researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers' Compensation database who had diagnoses of disc degeneration or disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in the hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.

After two years, only 26 percent of those who had surgery returned to work compared to 67 percent of patients who did not have surgery. Of the lumbar fusion subjects, 36 percent had complications and the re-operation rate was 27 percent for surgical patients. Permanent disability rates were 11 percent for cases and 2 percent for nonoperative controls.[10]

In what might be the most troubling finding, researchers determined that there was a 41 percent increase in the use of painkillers, with 76 percent of cases continuing opioid use after surgery. Seventeen surgical patients died by the end of the study.

The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs do not work well according to the study's lead author, Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine. His study concluded:

"Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a Workers' Compensation setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor return to work status."

Do you think MDs are telling their “back” patients of his opinion?

Another fascinating comparative study from Washington State found when worker comp patients had a choice in treatments for LBP, 42.7 percent of workers who first saw a surgeon had surgery in contrast to only 1.5 percent of those who first saw a chiropractor had surgery.[11]

Do you think surgeons are telling patients about this study?

Best Portal of Entry

At play is another issue that goes unmentioned.

Obviously if MDs were to follow the Choosing Wisely model, the biggest issue would not be whether providers should take images of LBP cases; instead, a more important issue should be for the MD to admit they are poorly trained to manage musculoskeletal disorders. Musculoskeletal disorders, specifically spine-related disorders, are just not their ball of wax, but they won’t tell anyone!

If the guidelines were followed, just as a patient with a toothache would be instantly referred by an MD to a dentist, 90% of patients with non-specific problems should be referred to a qualified DC.

This is not a novel idea. Research has already shown much of this waste in spine care would be eliminated if MDs were to refer “back” cases to DCs first as recommended by an in-depth study of internal data from Optum Health research by David Elton, DC, and Thomas M. Kosloff, DC, who co-authored “Conservative Spine Care: The State of the Marketplace and Opportunities for Improvement.”[12]

This study of more than 16 million episodes between 2010-2013 allowed for detailed analysis down to the level of each individual provider in each state in the country. Their study found chiropractors were the best portal of entry with lower costs and better outcomes.

Has any MD ever told patients about this study?

An internal analysis of 1.4 million non-surgical back pain episodes by Optum Health determined the best track to take for cost efficiency begins with a patient consulting a chiropractor first.[13] When a chiropractor was the first provider, treatments were “well-aligned with clinical evidence; the least fragmentation of care; low rates of imaging, injections, and prescription medications; and low total episode cost when manipulation is introduced within the first 10-days of the episode.”

They also found when manipulation was not provided at any time during the patient’s treatment that it to lead to higher total episode costs when using only medical spine care methods.

Poster Child

Not only costly and clinically ineffective, medical spine care also has led to the current opioid crisis and tsunami of failed back surgery.

This dire situation—inept MDs, opioids, ESI and fusions—has led to a “national scandal” according to Mr. Mark Schoene, the editor of an international spine research journal, The BackLetter.

He wrote an exposé, “U.S. Spine Care System in a State of Continuing Decline”:

Medical spine care is the poster child of inefficient care…such an important area of medicine has fallen to this level of dysfunction should be a national scandal. In fact, this situation is bringing the United States disrespect internationally."

Indeed, the bottom line in the new report, First, Do No Harm, should have emphasized DCs as primary spine care providers in order to reduce waste. Instead, it mistakenly suggests we not use the most scientific tool we have—the use of xray imaging. This issue of imaging is secondary to the primary care issue to refer to DCs since it is well proven MDs are inept in spine care evident by the poor results, opioid pandemic, and abuse of spine surgery.

Lack of Informed Consent

Legally and ethically, there is another elephant in the medical room that goes unrestrained damaging millions of patients annually—the issue of Informed Consent.

Studies have found patients entering hospitals for planned procedures are likely to find as few as 26 percent of consent forms cover the four basic elements of informed consent—nature of procedure, benefits, risks and alternatives.[14] In the typical medical Informed Consent, patients receive either a “generic consent-to-treat” document or a “fill-in-the-blank” document and rarely told of alternatives. Of course, one topic of omission concerns chiropractic care.

It is not surprising to find in a recent survey of 402 physicians, 87 percent reported that “most” or “some” of their patients were under- or misinformed.[15]

This is a huge issue the chiropractic profession has ignored that would illustrate to the public the continued boycott of chiropractic care by biased MDs, hospitals, and medical organizations are geared to profit rather than following guidelines to use nondrug treatments beforehand.

The new guidelines published by the American College of Physicians[16], the Journal of the American Medical Association[17], and the Food and Drug Administration[18]. now recommended by

This is not a new guideline. In 2010 the North American Spine Society also admitted spine fusion should be a last resort and recommended spinal manipulation—5 to 10 sessions over 2 to 4 weeks—should be considered before surgery.[19] In 2011, North Carolina Blue Cross/Blue Shield announced it will no longer pay for spine fusion if the sole criterion is an abnormal disc.[20]

Many spine experts now suggest chiropractors should be considered America’s primary spine care providers by virtue of their superior educational training and clinical effectiveness.[21]

The boycott of chiropractic care has perpetuated this current prescription opioid abuse since 29.9% of prescription painkillers are for low back pain according to a study, Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain. Imagine if these patients sought chiro care beforehand, the millions of people living without chronic pain or drug abuse.

The Joint Commission defined Informed Consent as:

Informed consent: Agreement or permission accompanied by full notice about the care, treatment, or service that is the subject of the consent. A patient must be apprised of the nature, risks, and alternatives of a medical procedure or treatment before the physician or other health care professional begins any such course. After receiving this information, the patient then either consents to or refuses such a procedure or treatment.

According to the Call to Action section in the First, Do No Harm report, patients are entitled to Informed Consent in the Choosing Wisely program:

3. The concepts of “choosing wisely” and shared decision-making must become the bedrock of provider-patient communications. Patients need objective information, based on evidence and well-vetted clinical guidelines, to help them understand treatment choices and their risks and benefits – this includes doing nothing and taking a wait-and-see approach. The cost of different treatment choices must be made known to patients BEFORE things are done so that patients have an opportunity to factor their ability to pay into the equation. Patients need the opportunity to express their preference(s) and to have them respected.

This sounds great, but my experience tells me it is not done in medical spine care—patients are rarely, most likely never, told chiropractors are a good alternative now recommended in the guidelines published by the American College of Physicians[22], the Journal of the American Medical Association[23], the Food and Drug Administration[24] and the Joint Commission.

Although this report wants doctors and patients to choose wisely as to their treatment, can we DCs expect MDs to mention nondrug alternatives for spine-related disorders?  Perhaps if it’s physical therapy, but not chiropractic.

In my nearly 40-year career in chiropractic, I have never had a new patient tell me their MD advised them chiropractic is a viable alternative to surgery. Instead, what I hear most often is the voodoo—“if you don’t have my surgery, you’ll be paralyzed and if you go to a chiropractor, he’ll paralyze you.” I am not joking.

If you recall the medical war against chiropractors, in the 1960s the Joint Commission was in cahoots with the Committee on Quackery’s witch-hunt against chiropractors threatening to ban any MD or hospital that dealt with chiropractors.

Today the Joint Commission has changed its tune in light of this opioid crisis and now includes a new element of Informed Consent required by hospitals to provide or educate patients about nondrug alternatives:

“One of the new pain management elements of performance requires that organizations provide non-pharmacologic pain treatment modalities…including chiropractic therapy.”

In 2108, the Joint Commission stated this responsibility in its Revisions to Pain Management: R3 Report: Pain assessment and management standards for hospitals:

EP 2: The hospital provides nonpharmacologic pain treatment modalities. Rationale: While evidence for some nonpharmacologic modalities is mixed and/or limited, they may serve as a complementary approach for pain management and potentially reduce the need for opioid medications in some circumstances. The hospital should promote nonpharmacologic modalities by ensuring that patient preferences are discussed and, at a minimum, providing some nonpharmacologic treatment options relevant to their patient population. When a patient’s preference for a safe nonpharmacologic therapy cannot be provided, hospitals should educate the patient on where the treatment may be accessed post-discharge. Nonpharmacologic strategies include, but are not limited to: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.

This is a huge breakthrough by the main policeman in medical care—the Joint Commission. This revision should be heralded by every state and national chiropractic organization as if it were the Voting Rights Act for chiropractors. If MDs and hospitals were to follow this revision, it would open access to chiropractors for millions of patients.

Of course, mainstream medical will conceal this revision until they are called out by chiropractors. Until we take this revision public with a new PR campaign, it will be ignored or abused by hospital staffs.

Both the Do No Harm report and Joint Commission clearly state the need for Informed Consent to educate patients as to the nature, benefits, risks, alternatives and costs, but, realistically, the high number—87%--of MDs who fail to give Informed Consent about alternatives remains a roadblock for patient access to DCs.

This Joint Commission standard is not voluntary, but a legal requirement that has been ignored every time chiropractic care is not mentioned as a viable alternative. This noncompliance with federal statues must become a national issue championed by our associations if the public is to learn they have the right to choose wisely.

As well, case law in New Jersey also states the legal requirement of Informed Consent including those “the physician does not recommend”, most likely chiropractic. Obviously the court realized the medical bias against chiropractors. The Supreme Court of New Jersey ruled in the case of MATTHIES V. MASTROMONACO [Supreme Court of New Jersey. 160 N.J. 26, 1999]:

“For consent to be informed, the patient must know not only of alternatives that the physician recommends, but of medically reasonable alternatives that the physician does not recommend.”

Yet to this day most MDs fail to refer to chiropractors and, thus, fail to give patients full Informed Consent. How can a patient choose wisely when this valuable information is withheld from them by a chirophobic MD?

When MDs withhold proven nondrug treatments from patients as the new guidelines recommend, this lawlessness puts patients in peril with the overuse of opioid painkillers and disabling spine surgeries.

As editor Mark Schoene opined:

“One can make the argument that the most perilous setting for the treatment of low back pain in the United States is currently the offices of primary care medical practitioners. This is simply because of the high rates of opioid prescription in these settings.[25]

It’s past time to give patients the freedom of choice to avoid this “perilous setting” in medical offices by giving them the right to choose wisely a nondrug treatment.

The Biggest Choice

The First, Do No Harm report also states:

Physicians play a critical role in initiating conversations about appropriate care with patients and also with other clinicians. Choosing Wisely is about doing the right thing for patients and avoiding care that could harm them.”

This assumes the physicians are not chirophobic.

If “Choosing Wisely is about doing the right thing for patients and avoiding care that could harm them,” why do they not admit medical primary care physicians have been shown to be “inept” in academic training on musculoskeletal disorders,[26] more likely to ignore recent guidelines,[27] and more likely to suggest spine surgery than surgeons themselves?[28]

This is a much bigger issue than simply taking xrays or ignoring Informed Consent. Inept MDs have created this opioid painkiller problem by funneling unwitting patients to promiscuous prescribers at Pain Clinics who, in turn, refer cases into the hands of spine surgeons working a debunked “bad disc” diagnosis and too often leave patients with horrible results—opioid addiction or failed back surgery in up to half the cases.

In fact, research by Dr. Nancy Epstein utilizing a second opinion surgeon documented that previous spine surgeons recommended “unnecessary” (60.7%), the “wrong” (33.3%) or the “right” (6%) operations. This equates to  94.0% of cases were given unnecessary or wrong recommendations for surgery.[29]

How often are patients told of this research?

Dumb Docs

Dr. Marc Siegel at FOX News addressed the largest problems in medical back pain practice, “We’re getting a growing awareness of two things: the abuse of back surgery and the abuse of opioids.”[30] He also admitted the average MD has only 9 hours on the “back.”

That revelation would speak volumes to patients if they only knew their PCP MD is poorly trained.

 Richard Deyo, MD, MPH, also mentioned the problem with physician incompetence in diagnosis and treatment of low back treatments:

"Calling a [medical] physician a back-pain expert, therefore, is perhaps faint praise–medicine has at best a limited understanding of the condition. In fact, medicine's reliance on outdated ideas may have actually contributed to the problem."[31]

Scott Boden, MD, director of the Emory Orthopedics & Spine Center, also admits, “Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders.”[32]

Today the consensus among researchers agrees medical primary care physicians are actually the least educated to diagnose and treat musculoskeletal chronic pain problems simply because they do not adequately study musculoskeletal disorders in medical school.[33]

In terms of basic competency, medical investigators concluded, “We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.”[34]

In a survey of family care physicians, 51 percent privately admitted that they had insufficient training to address musculoskeletal issues.[35]

This is undoubtedly a low estimate; plus, medical students are taught the standard outdated medical spine treatments that have been proven ineffective (drugs, shots and surgery) and, due to chirophobia—the bias against chiropractors—med students have not learned the benefits chiropractors bring to the table nor are they taught to refer ‘back’ patients to chiropractors as the primary spine providers.

Bad Disc Scam

If MDs are to be totally truthful with patients about Choosing Wisely, they also must tell them about the bogus “bad disc” scam that leads to unnecessary spine surgery. This remains the elephant in the room only the bravest MDs will discuss openly since spine surgeons are the wealthiest and most powerful of all MDs.

Without question, we see in spine care too much emphasis is placed on images showing disc abnormalities known to be ubiquitous in pain-free people. The “you got a bad disc” explanation remains urbane lore that greedy surgeons and hospitals gladly perpetuate. There is simply too much money in spine care to mention the ‘bad disc’ diagnosis is outdated.

The initial MRI research by Drs. Scott Boden and Sam Wiesel in 1990 found “bad discs” and age-related pathologies in pain-free people that began the investigation into the suspect disc surgery that continues today.

I am not alone in my criticism of spine fusions; in fact, I am Johnny-come-lately. In 2004 noted spine researchers Rick Deyo, Alf Nachemson, and SK Mirza also mentioned the need for restraint in their article, “Spinal-Fusion Surgery — The Case for Restraint”, published in the New England Journal of Medicine:

“The use of spinal-fusion surgery is increasing rapidly in the United States. Most of these expensive, complex procedures are now being done for back pain and degenerative disease. Spinal fusions require long operations and are associated with an increase in the rate of complications, particularly in older patients. The benefits of surgery may be only modest, and pain relief is affected by many factors besides the anatomy. The authors of this article argue for restraint in the use of spinal-fusion surgery and for controlled trials to define more clearly the associated benefits and the indications.”

This controversy came to light again in November, 2014, when the Mayo Clinic released its review by Waleed Brinjikji, MD, and his colleagues, “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations.” 

This Mayo review found a consensus among 33 MRI studies from around the world that undermines the rationale for fusion surgery based solely on this ‘bad disc’ idea that is used to lure unsuspecting patients into disc fusion surgery.

This revelation has become the largest crack in the Great Wall of the Disc Dynasty as the primary cause of back pain, but this medical myth remains very much alive to railroad patients into questionable back fusions.

If Informed Consent includes the whole truth, it’s past time for the medical professionals to discuss the many research studies showing wrong diagnosis, unnecessary surgery, and failed back surgery syndrome.

As well, the natural resorption of discs is rarely mentioned nor is the fact chiropractic care has been shown to help avoid fusion surgery as well as helping failed back surgery patients—all important points never discussed by PCPs or surgeons.

Although the Choosing Wisely program and the Do No Harm report were well-intentioned to avoid waste in medical care, methinks in regards to spine care they both badly missed the boat filled with much bigger issues than xrays.

The problem isn’t just too many unnecessary images, it’s the bigger problems of too much money, too few ethics, too many inept MDs, too many opioids, too many ESIs, and too many spine surgeries.

Why hasn’t the ACA ever broached these issues in its public relations program if they truly wanted to have patients and MDs choose wisely in order to Do No Harm?

I urge the ACA bigwigs to expand its version of Choosing Wisely to include each of the important issues I’ve mentioned. However, I don’t expect them to do anything of the sort.

As I discovered in 2002 when the ACA president asked me to research PR, I wrote an ACA PR Report, but nothing ever materialized from this fascinating study into previous PR campaigns in the US and around the world.

In Part Four, I will show the biggest irony about the ‘new’ ACA Choosing Wisely advocacy with its selection of the keynote speaker at the McAndrews Leadership Lecture at the upcoming NCLC.

If you think the Choosing Wisely program is problematic for chiropractors, the ACA’s choice for this keynote speaker is even more confusing.

Log on to read Part Four: Gaslighting Chiropractic



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

[2] Donald R Murphy and Eric L Hurwitz, Application of a diagnosis-based clinical decision guide in patients with neck pain, Chiropractic & Manual Therapies 2011, 19:19

[3] Donald R Murphy and Eric L Hurwitz, “Application of a diagnosis-based clinical decision guide in patients with low back pain,” Chiropractic & Manual Therapies 2011, 19:26

[4] Donald Murphy in private communication with JC Smith, July 20, 2012 

[5] Murphy DR, Hurwitz EL, Gregory AA, Clary R. A non-surgical approach to the management of lumbar

spinal stenosis: a prospective observational cohort study. BMC Musculoskelet Disord. 2006;7:16.

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

[7] Donald Murphy in private communication with JC Smith, July 20, 2012 

[8] Chiropractic Approach to Lumbar Spinal Stenosis Part II: Surgery and Treatments By Carol Marleigh Kline, JACA Online editor, MAYJUNE 2008

[9] DR Murphy, Clinical Reasoning in Spine Pain volume 1, Primary Management of Low Back Disorders Using the CRISP Protocols © Donald Murphy 2013, p. viii

[10] Nguyen TH, Randolph, DC, et al. Long-term outcomes of lumbar fusion among workers' compensation subjects: an historical cohort study. Spine, Feb. 15, 2011;36(4):320-331.

[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258106/

[12] Thomas M. Kosloff, DC, David Elton, DC, Stephanie A. Shulman, DVM, MPH, Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Amanda Solis, MS, Conservative Spine Care: Opportunities to Improve the Quality and Value of Care, Popul Health Manag. Dec 1, 2013; 16(6): 390–396.

[13] Thomas M. Kosloff, DC, David Elton, DC, Stephanie A. Shulman, DVM, MPH, Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Amanda Solis, MS, Conservative Spine Care: Opportunities to Improve the Quality and Value of Care, Popul Health Manag. Dec 1, 2013; 16(6): 390–396.

[14] Bottrell MM, Alpert H, Fishbach RL, Emanuel LL. Hospital informed consent for procedure forms: facilitating quality patient-physician interaction. Archives of Surgery. 2000;135:26-33.

[15]  Executive summary of findings from a national survey of physicians. Conducted by Lake Research Partners. February 2009. http://www.informedmedicaldecisions.org/pdfs/WhitePaperExecutiveSummary.pdf Accessed June 9, 2011.

[16] https://www.acponline.org/acp-newsroom/american-college-of-physicians-issues-guideline-for-treating-nonradicular-low-back-pain

[17] https://jamanetwork.com/journals/jama/article-abstract/2616395

[18] https://www.fda.gov/downloads/Drugs/NewsEvents/UCM557071.pdf

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

[21] Donald R Murphy et al.,  “The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States,” Chiropractic & Manual Therapies 2011, 19:17 doi:10.1186/2045-709X-19-17

[22] https://www.acponline.org/acp-newsroom/american-college-of-physicians-issues-guideline-for-treating-nonradicular-low-back-pain

[23] https://jamanetwork.com/journals/jama/article-abstract/2616395

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