EBC or unscientific cult?
Faith Restored
By
JC Smith
Sometimes you just never know what gifts you’ll be given, nor do they all come wrapped in bows and boxes. For me, Christmas came early this year on the first weekend in December when I attended the FCER seminar at SCUHS in Whittier, not far from my old hometown of Upland, enabling me also to visit my relatives on this business trip. My first day back quickly reminded me how SoCal had lost its charm when it took me two hours to commute 30 miles to the campus on the notorious Santa Ana freeway.
Foremost, however, was my chance to hear some of the most renowned researchers and educators in this profession and to meet some of the staff and students on campus. In effect, this seminar was a mini-RAC with a touch of the LA-style—I must say when I was matriculating at Life College, co-eds certainly didn’t look like attendees from this SoCal chiro campus such as student body president Brittney Cicon and instructor Christine Lemke!
As one presenter mentioned, this seminar was “preachin’ to the choir,” but it did make for an informal meeting that was fun as well as enlightening with clever repartee tossed about among the presenters and parishioners in the audience. Personally, learning of the growth of chiropractic research and the increasing evidence supporting what we do in chiropractic, this seminar restored my faith in this profession, at least in the science of chiropractic.
Overcoming Barriers
The theme of this FCER show was “Translating Evidence into Practice.” With the rush toward Evidence Based Medicine, these speakers brought together the process, the problems, and pitfalls of gathering evidence and, more so, making it become real in practice and noticed among the public.
Practicing on blind faith gained solely from practice managers gurus, charismatic demagogues or faith-based educators is tenuous, to say the least, but to learn of the emerging evidence for SMT is one we can hang our hats on with third-parties. With only 15% of medical interventions supported by solid scientific evidence according to the Eddy study in 1991, and the fact that the standard medical care for LBP is terribly outdated and unsupported according to the current 17 international guidelines, this seminar spoke to the heart of chiropractic’s dilemma to get itself recognize as evidence-based care after years of being viewed as an “unscientific cult,” ya folla?
As Meridel Gatterman mentioned, evidence-based practice is defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients,” according to a definition by Dr. David Sackett in 1998. She also mentioned the barriers to individual DCs doing research, such as time constraints, lack of funding/training, lack of critical thinking by DCs, as well as the fear by field docs of cookbook practices, cost containment guidelines developed by academians, and confusion over conflicting guidelines.
The bias against chiropractic is also a major problem. Indeed, it’s one thing to be a science-based profession seeking improvements in clinical care as technology and research evolves, but the jump from a cultish, faith-based image to a highly regarded scientific-based profession is a paradigm shift that only chiropractic still faces today.
Improving Quality & Costs
Robert Mootz mentioned the move toward quality improvement, while evident all around our lives in other industries, is absent in academics and healthcare. Presently, “there is no infrastructure to support EBM,” according to Dr. Mootz. Thankfully, the past few decades of worldwide research approaching over 60 well-done RCTs on neck and LBP, accumulating with the recent UK BEAM Team Trial just released in the BMJ, has shown the cost and clinical effectiveness of SMT for LBP, yet the challenge to integrate chiropractic care into the mainstream remains filled with political pitfalls, professional bias, economic injustices, and internal strife that are hurdles that we still must jump.
Famed medical economist, Pran Manga, PhD, a leading proponent for chiro care for LBP, mentioned his frustration of the politics of healthcare when he noted that his own province of Ontario in Canada recently “de-listed” chiro care from its Medicare system, the fist time any jurisdiction has done so. Ironically, this decision by the premier came without any discussion or debate at a time when EBM shows the overall effectiveness of SMT for LBP and, ironically, occurred in Dr. Manga’s own backyard. As we heard often, gathering scientific research is one thing, transforming evidence into practice is another.
Applying the Evidence
Dr. Jennifer Bolton, instructor at the UK chiro college in Bournemouth, also mentioned the lack of integration of EBM into practice. “There continues to be a huge gap between clinical research and clinical practice in all health care professions.” She quoted the Oct. 2004 edition of the BMJ, “Integration of evidence into clinical practice remains the biggest challenge for EBP.” As Dr. Bolton emphasized, translating evidence into practice is “not about whether or not chiropractic is evidence-based, it is about clinicians adopting an evidence-based approach.”
She urged field docs to become “research users” to close the loop between evidence and practice, as well as to become “research providers” who provide case studies, clinical trials, and BET (best evidence topics) for publications. In fact, although most researchers rely on RCTs, JAMA disclosed that during the past 100 years, nearly 40% of its articles published were case studies. Throughout all of the health care professions, however, Dr. Bolton felt this challenge of transforming evidence into practice often looked like putting a “square peg of research in the round hole of clinical practice.”
Part of the problem of expanding our data base is that most field doctors are unaware how to conduct clinical trials, BETs, and case studies. Ron Rupert, DC, Michael Patterson, PhD, and Todd Nick, PhD, spoke of methods to assess and understand the available current evidence and how to interpret statistics. While the older generations of field docs may be intimidated, hopefully the younger generation will not, as Dr. Bolton mentioned that at her college, all students must write an evidence-based case report before graduation.
Dr. Dana Lawrence, labeled by FCER host Dr. Tony Rosner as “the kingpin of chiropractic journals” for his efforts as the past 23-year editor of the JMPT before moving on to the Palmer Center for Chiropractic Research, spoke of the evolution of scientific chiropractic publications. Until JMPT was created in 1981 by National College, the only mention of chiropractic in medical journals were filled with bias, a point Dr. Roy Hildebrand, the original editor, used to convince Medical Indicus to include peer-reviewed chiropractic articles.
When the JMPT first began, the staff didn’t even have a computer, everything was done by hand, and Dr. Lawrence admitted that he felt totally untrained to be a biomedical journalist. He urged for more case studies to expand our data base since only 80 people now are doing research in chiropractic. “With a larger data base, political battles are easier and education is easier. Communication is essential if science is to progress.”
Junk Science & Junk Reporting
While communication is a key, it also becomes frustrating when “junk reporting” distorts the truth of EBM as we recently witnessed when Parade magazine published an article about back pain that was without merit, touting medical methods disproved by the latest research. Dr. Rosner mentioned other cases of junk reporting by biased authors like Jane Brody who tweaked the original results on strokes to push an anti-chiropractic agenda saying that one in 20,000 adjustments caused a stroke.
He also mentioned “sausage” publications using the same data in different publications by the same author; bias as in the Cherkin study comparing SMT with PT and placebo or the Balon Asthma study in the NEJM that minimized the affect of SMT although the patient exit surveys reported an improvement on the average over 50%; conflicts of interest when the Phillip Morris tobacco company sponsored a study that proclaimed smoking helped contain costs since smokers lose 3-4 years of life that would save $30,000 in reduced healthcare costs.
Of course, Dr. Rosner mentioned the huge medical backlash by the orthopedic society after the AHCPR acute low back pain guideline #14 in 1994 recommended SMT over back surgery that was enough to nearly eviscerate that agency and kill its next study on headaches, which was salvaged only after the FCER sponsored the Duke study on headaches showing that SMT was the most effective treatment for cervicogenic headaches.
Apparently the last thing the orthopedic surgeons wanted was the US Public Health Service endorsing SMT for LBP and headaches. As Drs. Rosner and Manga both mentioned it’s one thing to do the research to obtain useful evidence, but it’s another matter to overcome bias attitudes, conflicts of interest, political deals, and skewed interpretations that distort the studies.
It’s also another issue to overcome the “distributive injustice” that Pran Manga mentioned when economic interests suppress innovations that may reduce healthcare costs as we’ve constantly seen when hospitals prefer expensive, ineffective spine surgeries in lieu of SMT. In effect, SMT is too cheap to interest hospital administrators: ironically, being the cheapest mousetrap works against us in this era of managed health care for profit.
The Impact of Research on Legislation
Dr. Jay Triano of the Texas Back Institute admitted, “We can’t solve social problems in practice, only health problems…We’re not out for acceptance now, but credibility. Acceptance comes later.”
Actually, the evidence gained from the plethora of research has been useful politically to enhance our credibility in the eyes of legislators, according to Dr. George “Mac” McClelland, present ACA chairman who spoke of the legislative success on Capitol Hill that occurred primarily from the wealth of recent research showing the cost and clinical effectiveness for SMT. Combined with the many successful personal relationships formed over the years between Congressmen and chiropractors, the evidence gave these friendly legislators the research they needed to argue our case.
Indeed, with facts in hand, it was a lot easier to convince legislators to include DCs in the military and VA health systems. From zero federal money for research in the 1980s, now chiropractic researchers get over $20 million, thanks to the research evidence and friends in Congress like Sen. Tom Harkin.
As Dr. McClelland mentioned, “Many DCs may not see the immediate relevance of chiropractic research on their practices; however, they should understand that chiropractic related research and research projects have played an invaluable role in promoting the expansion of chiropractic services in federal and private programs, as well as public support and acceptance of chiropractic care. The overall impact is PRICELESS…”
Not only is it priceless for legislative efforts, but translating research into practice will become invaluable for field docs to learn what works best in these cases. As Dr. Triano mentioned, the CCPGG will announce in mid-2005 its results as to which methods are most appropriate. Granted, there will be growing pains for some techniques that cannot support its claims as Dr. Gatterman mentioned the firestorm when she and her partners published their meta-analysis of best practice techniques for LBP in JMPT.
That’s exactly the goal of Evidence-Based Care—to separate the wheat from the chaff. As we’ve found with medical care, however, the NAS mentioned on the average it takes 15 years for a new medical method to be implemented into mainstream practice, which explains why the use of and referral for SMT for LBP has been so slow to develop among medical practitioners. Dr. Phillips have a luncheon talk on the integration of research into chiropractic practice, so hopefully the graduates of our more notable chiro colleges will be well versed in EBC rather than steeped in chiropractic dogma based on anti-science disguised as philosophy.
The same may happen for DCs who use what proves to be marginal methods that lack the clinical evidence demanded by EBM. No longer will technique entrepreneurs be able to say, “The lack of evidence doesn’t preclude the lack of effectiveness” as we heard in the Gatterman et al. study firestorm. Just as medicine has been slow to change, chiropractic may be just as intransigent to implement new guidelines to improve its outcomes.
Prevention & Cultural Diversity
Other interesting topics covered by Drs. Cheryl Hawk and Lisa Killinger enlightened us to putting prevention into practice. Dr. Hawk spoke about Health People 2010 (www.health.gov/healthypeople) and the Five-a-Day Program with many health tips and preventative measures available. As she mentioned, if you’re prone to practice prevention, “you don’t have to re-invent the wheel because the best evidence is already done.”
Dr. Killinger gave a thoroughly interesting talk on Cultural Competency in regards to treating minorities and their cultural/religious idiosyncrasies. Although most of our patients are white folks between 20-50 years, the growing minority groups will become a larger part of any practice, especially in the metropolitan areas like LA. For example, do you know which race has over twice the average incidence of disability due to low back pain in the US and higher rates of diabetes? Which groups have markedly higher incidences of heart disease, hypertension and diabetes?
As an American Muslim herself, she spoke of our need to be aware of the customs of minority religious groups. Simple gestures like direct eye contact may have completely different meaning than in the western white population. Certainly, giving a typical side posture manipulation may mean nothing to us, but to a Muslim or Asian it’s a sensitive issue since modesty is a paramount in those cultures. As Dr. Killinger said, “As chiropractors we become very de-sensitized about buttocks. To us, a buttock is just a muscle in the way of the sacrum, but for a patient this is a very sensitive and private area.”
The Greatest Gift
After two full days of lectures, my final gift came in the form of dinner with Dr. Reed Phillips and his lovely wife, Sandra. Although the mariachi band at their local Mexican restaurant made it difficult to hear, I was impressed to learn of the many projects both of them were involved with. As the old saying suggests, if you want something to get done, give it to someone with a full plate, including enchiladas and burritos.
As well as heading the university campus, Dr. Reed was just selected as Chiropractor of the Year by Dynamic Chiropractic, he remains chairman of the DVA CAC, and he’s on the board of CCE, to name a few of his many projects to improve this profession on many levels. His wife, Sandra, appears to be just as busy as her husband involved in numerous products for home-care, along with raising a family of 8 children. She has also co-authored a self-help book, “How Successful People…Keep Their Lives Out of the Toilet,” perhaps the topic of a future chiro seminar?
All in all, this two-day sojourn to SoCal was a blessing in many ways—to visit with family and friends, to learn from the brightest and the best, and to enjoy the camaraderie of people who love what I love. I think this type of seminar would be well-received by the vast majority of the profession who remain unaware of the research and evidence that supports what we do, and I recommend every state association to consider hosting a similar event by the FCER.
As Jay Triano often says, “it’s not what we do that matters as much as what we say about what we do.” Now we can talk the talk and walk the walk with EBC in our hand rather than rhetoric based on pseudo-science, so-called philosophy. This is the trend of our future, and the quicker every field DC, faculty member, and student embrace the world of EBM, the quicker chiropractic will find both acceptance, success, and the credibility we’ve long sought.