Articles by JCS

Second Thoughts

Any Regrets?

 

Second Thoughts


The winter holidays bring not only the best in college bowl and NFL playoff games, but this annual milestone makes us reflect upon remembrances from yesteryear and hopeful resolutions for the future.

Certainly the New Year is a time when many people take stock to ask themselves if their accomplishments met their aspirations. Most often, many may have second thoughts and some regrets about the past year.

Did we do as well as we might have financially; did we select the best line of work; did we marry the right person(s); will our kids turn out okay; and what could we have done to be happier and healthier?

Career Regrets

As chiropractors, we also may have second thoughts about our profession as do medical professionals, such as how Obamacare will impact our careers. After the HMO fiasco—“Squeeze care to expand profits”—over the past two decades when we saw our incomes drop as clinical restrictions and paperwork increased, healthcare has become more stressful than ever before. Too often I hear many DCs speak regretfully about their career choice and this disappointment is not exclusively our problem.

For example, it was reported in 2012 just over half of all physicians (54%) would choose medicine again as a career, far less than in the previous year's report where 69% of physicians would choose medicine again.[1]

Overall, about 45% say their incomes are no better than that of many non-physicians, and another 45% admit "My income probably qualifies me as rich, but I have so many debts and expenses that I don't feel rich."

Only 11% of physicians say they consider themselves rich who, most likely, include spine surgeons. The average annual salary of a spine surgeon is now the highest paid of all doctors at $806,000 according to Bloomberg News.[2]

Burnout is giving many doctors second thoughts. Many medical physicians feel a sense of burnout according to a recent study of 7288 doctors published in the Archives of Internal Medicine that showed nearly one half (46%) reported at least one symptom of burnout.[3]

The recent demand for electronic health records has made doctors in all specialties feel swamped with paperwork considering one-third of physicians spend more than ten hours per week on paperwork and administration.

Spine Care Regrets

Healthcare reform has given many MDs second thoughts about a career in medicine. This frustration is most evident in spine care where every facet of medical spine care is under attack.

Although spine surgeons remain at the top of the medical heap in terms of income, their practices are experiencing second thoughts by payers with increasing denials of coverage from insurance companies for surgery as well as other procedures and tests that traditionally would have been approved in the past.

"The last two years have been extremely challenging," says Neel Anand, MD, director at Cedars-Sinai Spine Center in Los Angeles. "Seemingly, everything is being denied, including MRIs and CT scans. We spend at least 50 percent of our time, compared to two years ago, getting approval for patients and talking to non-medical personnel. Sometimes even then, we aren't able to get clearance for the surgery."[4]

Payer Regrets

In light of the lack of evidence for disc fusion surgery, does this really come as a surprise? This renaissance in spine diagnosis began in 1990 when research by Scott Boden et al.[5] followed in 1994 by a supportive study by Maureen Jensen et al.[6] found no clear correlation between disc abnormalities and back pain. 

Payers rightfully should have second thoughts about the discogenic theory of back pain since many researchers now chide disc abnormalities—the basis of disc surgery—as “trivial, harmless, and irrelevant” to the point of labeling them “incidentalomas.” [7] 

The biggest surprise should be it has taken over twenty years for the payers to follow the evidence-based guidelines in spine care. North Carolina BC/BS finally refuses to pay for fusions if the sole criterion is an abnormal disc.[8]

Several news sources also have had many second thoughts about medical spine care treatments, such as The New York Times[9] and The Wall Street Journal[10],[11], NPR[12], MSNBC.com[13], and Bloomberg[14] internet news.

Certainly, American healthcare organizations must now have serious regrets about the medical profession’s domination of spine care. These glaring research issues, poor clinical outcomes, and astronomical costs in medical spine care led the editor of an international spine research newsletter to have second thoughts when he said, “Spinal medicine in the US is a poster child for inefficient spine care.”[15]

Deadly Admission

Recently in the news we’ve seen the crisis of tainted epidural shots causing deaths from meningitis infections and the thousands of deaths from opioid narcotics, euphemistically called hillbilly heroin.

Since more than 16,500 people die from opioid overdoses every year, some MDs are having second thoughts, including the godfather of painkillers, Dr. Russell Portenoy, who campaigned for wider prescription of pain medications like Vicadin, OxyContin, and Percocet. Previously these opioids were used for interminable or long term cancer patients, but now have been extended to chronic pain patients, too.

“Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did,” Dr. Portenoy admits in an interview in The Wall Street Journal. “We didn't know then what we know now. I gave innumerable lectures in the late 1980s and '90s about addiction that weren't true."[16]

He originally argued that opioids were a "gift from nature" that were being forsaken because of "opiophobia" among doctors. "We had to destigmatize these drugs," said Dr. Portenoy.

"It had all the makings of a religious movement at the time," explained Steven Passik, a psychologist who once worked closely with Dr. Portenoy who admitted their message wasn't based on scientific evidence so much as a fanaticism to improve patients' lives. "It had that kind of a spirit to it." It also was highly profitable to Big Pharma to have MDs pushing their narcotics making addicts of people with chronic pain.

Education Regrets

This regret about painkillers is partially a byproduct of MDs who are untrained in the diagnosis and management of back pain and other musculoskeletal chronic pain disorders. This revelation ought to give everyone second thoughts about advice from their medical primary care physician.

Emory University faculty member and spine expert, Dr. Scott Boden, admitted over a decade ago that, “Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders.”[17]

Researchers attest that medical primary care physicians are actually the least educated to diagnose and treat musculoskeletal problems.[18]  Inexplicably, it was found that 50% of all medical schools do not teach even one class on this subject.[19]

Other researchers agree that medical primary care physicians are typically inept in their training on musculoskeletal disorders,[20] prone to ignore recent guidelines that do not recommended narcotics,[21] and more likely to suggest spine surgery than surgeons themselves.[22]

This lack of medical education for MSDs combined with the abuse of narcotics and the historical antipathy of MDs toward chiropractic providers makes for a deadly dose of mismanagement for the epidemic of chronic back pain.

Research Regrets

Despite the historical boycott of chiropractors by the medical profession, this era of evidence-based healthcare has been a blessing to chiropractors as many researchers are now having positive second thoughts about our brand of drugless care, if they can get by their inbred medical bias.

Unquestionably the medical demagogues who claim chiropractic is an “unscientific cult” have plenty of regrets now that the research supports chiropractic care over medical care for the majority of back pain cases.

Monumental changes in treatment policy by national and international guidelines now recommend chiropractic care as the first avenue of care for mechanical low back pain. For nearly 20 years now, comparative international studies have recommended manipulation over drugs, shots, or surgery (AHCPR-US[23], Manga-Canada[24], NICE-UK[25]).

In 2010, the North American Spine Society 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 or narcotics.[26]

However, convincing the spine surgeons of this policy change is the biggest problem. Research and guidelines may be fine until they cut into their bottom line.

For example, a recent study in Washington State to identify early predictors of lumbar spine surgery within 3 years after occupational back injury found a direct correlation between spine surgery and the type of spine providers. Not surprising, 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who first saw a chiropractor.[27]

This heavy inclination to do spine fusion surgery despite the unsupportive research illustrates the old adage: “If your only tool is a hammer, everyone looks like a nail.”

Public Regrets

After decades of the medical boycott and public defamation of chiropractic care, the public, payers, and politicians may have regrets they ever listened to the medical demagogues after the wake of addiction, disability, deaths, and depression left by the medical management of chronic pain.

Despite every effort by the AMA to slander our profession over the past century, now the public is having positive second thoughts about our brand of care. Public surveys repeatedly put chiropractors at the top of the list for mechanical back pain, such as Gallup[28], TRICARE[29], Consumer Report[30], as well as the Centers for Medicare & Medicaid Services Chiropractic Demonstration Project.  

The government is also having regrets about the corruption between MDs and drug companies as revealed by recent litigation by the Justice Department.[31] This medical payola, dubbed “pharmapayola,” is widespread with 84% of doctors who admit to a financial relationship with the drug industry between 2004 and 2009.[32]

In all, payments from drug companies to doctors totaled more than $760 million between 2009 and the second quarter of 2011.[33] Drug companies also spent at least $220 million last year on speaking fees to doctors who endorsed their products.[34]

Big Pharma bribing doctors, speakers, and journalists resulted in at least $10 billion in settlements with the federal government. The largest settlement occurred with GlaxoSmithKline's $3 billion fine and guilty plea to committing felony crimes. Abbott Laboratories settled for $1.6 billion and an agreement with Johnson & Johnson could result in a fine of $2 billion.[35]

The recent Senate investigation into device manufacturers bribing spine surgeons and medical journalists is another issue to give people pause.[36] These device companies entered into partnerships with surgeons and paid them "dividends" based on the number of surgeries they performed. “Dividends” is the industry term for kickbacks.

The huge salaries for spine surgeons do not include the royalties and commissions paid to some surgeons by surgical hardware manufacturers that often top the million dollar level as The Wall Street Journal revealed in an article, “Top Spine Surgeons Reap Royalties, Medicare Bounty.”[37]

For example, The Wall Street Journal revealed Dr. Kevin Foley at Memphis's Methodist University Hospital has had royalty agreements with Medtronic since 1996. The company paid him more than $27 million from 2001 to 2006, according to internal Medtronic documents reviewed by the Journal. On its website, the company discloses paying him another $13 million in royalties in the first three quarters of 2011 alone.[38]

Some MDs are now having second thoughts about the easy money from kickbacks from MRI centers after police arrested 14 physicians charging them with accepting bribes in exchange for referring patients. Police also arrested Orange Community MRI Executive Director Chirag Patel for allegedly paying a total of $51,500 in kickbacks to physicians during a 2-month period from early October to early December 2011.[39] Extrapolating this kickback over a 12-month period equates to $618,000.

Considering the many failings of the medical approach to back pain, beginning with the unnecessary spine fusions based on “false-positive” MRI diagnosis looking for disc incidentalomas, the over-use of addictive narcotic painkillers, the danger and ineffectiveness of epidural shots, and the pervasive corruption of MDs by Big Pharma, device manufacturers, and MRI kickbacks, a case can be made the medical management of chronic back pain is not only expensive and ineffective, it is scandalous.

Journalism Regrets

This New Year will bring more change to spine care if and when the media ends its bias against chiropractors and disseminates the truth about chiropractic care for the epidemic of back pain. But I’m not holding my breath as yet since most medical reporters are biased as I’ve encountered.

The recent exposé on CNN by Sanjay Gupta, Deadly Dose, illustrated his biased journalism. Dr. Gupta admitted the reported cause of 75% of patients’ addiction to painkillers was back pain, the focus of his program. In a 60-minute program he failed to mention any non-drug CAM treatment for chronic back pain.

Inexplicably, how can a renowned neurosurgeon and award-winning journalist like Dr. Gupta air a program on the ravages of drug addiction for chronic back pain and not mention the leading non-drug treatment in the world—chiropractic care?

His omission reveals his “professional amnesia” that cannot admit that his professional foes, those pesky chiropractors, are on the right track for a non-drug solution. Indeed, Gupta would be an unwelcome guest at the next NASS conference if he were to tell the truth about chiropractic care for the epidemic of back pain.

Despite being the third-largest physician-level profession in the country in midst of a worldwide chronic pain pandemic, the lack of presence in the media has been the second-most hindrance to our growth aside from the covert lingering medical boycott that continues to have chiropractic “wither on the vine.”

Unanswered Question

As we look back to 2012, one major event was the documentary, Doctored, by Jeff Hays and Bobby Sheehan. This probing film revealed the broken medical system and people seeking alternatives, but it left unanswered one huge question that it raised.

If you’ve seen the film, you will recall the sequence at the beginning when numerous DCs mentioned being called the Q-word by medical bigots. One after another chiropractors gave shocking stories of being insulted in public by medical bigots. I daresay every DC has been subjected to medical bigotry.

While racism, sexism, homophobia, and anti-Semitism are no long politically correct, it appears medical bigotry remains acceptable in the health profession and in the media if Sanjay Gupta is typical.

The most poignant example was J. Michael Flynn’s anecdote about his brother killed in Vietnam and his mother who endured the public humiliation caused by a local MD who refused to bowl if Mike’s father was allowed. Like the proverbial Jim Crow, MD, blatant medical bigotry remains entrenched, just as racism remains steadfast in the Deep South.

Certainly these are painful epithets the public has also heard millions of times from biased MDs, but the film never did answer this disparagement with proof that we DCs have been right all along when it comes to the best brand of spine care for the majority of patients.

My book, The Medical War Against Chiropractors, not only detailed the roots of the medical war with the major events and players involved, but the second part of my book gave the new evidence that vindicates our profession.

I believe this is the route we need to take to explain to the public why they mistakenly think the way they do about our profession. Even the WOC testimonials now used by the F4CP will not overcome this medical sentiment. Sadly, few have explained the medical bigotry that permeates health care in America.

Indeed, as I have written and history will show, the medical war against chiropractors has fallen on the wrong side of justice, the wrong side of research, and the wrong side of health care, but much more positive and probing investigative journalism is necessary to clarify and enhance our image by overcoming decades of medical propaganda.

If and when chiropractic care receives the publicity it deserves to help millions of patients and save billions of dollars, the challenge remains to reach the majority of Americans who have not experienced our brand of care to expand our market place.

As the last vestiges of medical bigotry fade as the evidence mounts in our favor, perhaps then the public will get the best of both worlds that includes—like the old bumper sticker once said—“chiropractic first; drugs and surgery last.”

So, as we enter the New Year, let us proceed with our heads held high as the century-long medical war against chiropractors (and all CAM providers) wanes as more evidence emerges to prove that we DCs have been on the right track despite the bumps in the road.

Indeed, if Section 2706 in Obamacare prevails, it may be the first time in American history when alternative and complementary care is freed from allopathic dominance, giving the public its first glimpse of freedom of choice in healthcare.

 Just imagine over 100 years ago when DD Palmer  proclaimed, “Is it possible that the science of Chiropractic has arrived before its time?”[40] Certainly this visionary was right about many things that can make us proud.

Today’s explanations of chiropractic are not the quaint concepts of “pinched nerves” from yesteryear. Neurophysiologists now suggest the effects of a “bad back” may lead to a myriad of problems such as somatovisceral reflexes and cerebral degeneration via altered neurotransmitters. In fact, the research vindicates what DD Palmer tried to explain as “functionating” although much more has yet to be discovered.

Hopefully our time will arrive this next year for a national breakthrough—an unabridged acknowledgement that our brand of spine care is the best drugless, non-surgical solution for the pandemic of pain.

The proof is positive and research studies cannot be clearer that chiropractic stands at the top of spinal treatments as Anthony Rosner, PhD, testified before The Institute of Medicine: “Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”[41]

Now is the time for the public to learn of our success and to have no second thoughts about our brand of drugless care.

 



[1] Mark Crane, Physician Frustration Grows, Income Falls -- But a Ray of Hope,  Medscape Business of Medicine, Apr 24, 2012

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

[3] Paul Griner, MD, Why Are MDs Burning Out in Record Numbers? Nov. 27, 2012.

[4] Laura Miller, 10 Key Trends in Spine Surgery for 2013, Becker’s Spine Review, November 12, 2012

[5] 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.

[6] 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.

[7] Richard Deyo, MD, MPH and Donald Patrick, PhD, MSPH, Hope or Hype, The obsession with medical advances and the high costs of false promises. 2005 AMACOM books.

[8] Crownfield, Peter W., “Chiropractic Before Spine Surgery for Chronic LBP,” Dynamic Chiropractic, vol. 30, no. 11, May 20, 2012.

[9] Elisabeth Rosenthal, How Back Pain Turned Deadly, New York Times, Published: November 17, 2012

[10]Top Spine Surgeons Reap Royalties, Medicare Bounty,” by John Carreyrou And Tom McGinty, Wall St. Journal, Dec. 20, 2010

[11]Medicare Records Reveal Trail of Troubling Surgeries” by John Carreyrou and Tom McGinty, Wall St. Journal, March 29, 2011

[12]Surgery May Not Be the Answer to an Aching Back,” by Joanne Silberner, NPR, April 6, 2010.

[13]  Back Surgery May Backfire on Patients in Pain,” by Linda Carroll, MSNBC.COM, Oct. 14, 2010

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

[15] The BACKPage editorial vol. 27, No. 11, November 2012.

[16] Thomas Catan and Evan Perez, A Pain-Drug Champion Has Second Thoughts, WSJ, December 17, 2012

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

[18] AD Woolf, B Pfleger, “Burden of Major Musculoskeletal Conditions,” Bull World Health Organ 81/09 (2003):646-656.

[19] Matzkin E, Smith MD, Freccero DC, Richardson AB, Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005, 87-A:310-314

[20] Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/ 11 ( November 2004).

[21] 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.

[22] SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, And Surgeons For Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115.

[23] 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)

[24] 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

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

[26] 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

[27] Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM.,

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State.,Spine (Phila Pa 1976). 2012 Dec 12.

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

[29] 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.

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

[31] Shannon Brownlee The Latest Big Pharma Scandal, TIME, Jan. 30, 2012;
Read more: http://ideas.time.com/2012/01/30/the-latest-big-pharma-scandal/#ixzz2FR9Vj1eU 

[32] Eric G. Campbell, PhD; Sowmya R. Rao, PhD; Catherine M. DesRoches, DrPh; Lisa I. Iezzoni, MD; Christine Vogeli, PhD; Dragana Bolcic-Jankovic, MA; Paola D. Miralles, BS, Physician Professionalism and Changes in Physician-Industry Relationships From 2004 to 2009, Archives of Internal Medicine, November 2010

[33] Charles Ornstein, Tracy Weber and Dan Nguyen, Piercing the Veil, More Drug Companies Reveal Payments to Doctors, ProPublica, Sept. 7, 2011,

[34] Charles Ornstein, Tracy Weber and Dan Nguyen, Piercing the Veil, More Drug Companies Reveal Payments to Doctors, ProPublica, Sept. 7, 2011,

[35] Katie Thomas and Michael S. Schmidt, Glaxo Agrees to Pay $3 Billion in Fraud Settlement, New York Times, July 2, 2012

[36] John Carreyrou and Tom Mcginty, Top Spine Surgeons Reap Royalties, Medicare Bounty, WSJ, December 20, 2010

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

[38] John Carreyrou and Tom Mcginty, Hospital Bars Surgeon From Operating Room, WSJ,  April 13, 2011

[39] Laird Harrison, 14 Physicians Accused of Kickbacks for Imaging Referrals, Medscape Medical News, Dec 17, 2011

[40] DD Palmer, The Chiropractor’s Adjuster: The Text-Book of the Science, Art and Philosophy of Chiropractic (Portland, Oregon:  Portland Printing House) (1910):847

[41] Testimony before The Institute of Medicine: Committee on Use of CAM by the American Public on Feb. 27, 2003.

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