Events during the last two weeks of April, 2014, were shocking for the chiropractic profession when defamatory articles appeared in two national publications, Forbes and USA Today.

The scandalous Forbes article was laden with blatant bias on the status of chiropractic in the Medicare annual report by a professor of medicine at Johns Hopkins who obviously has lost all objectivity that led to a remarkably vociferous push-back from both the chiropractic profession and the public whereas the USA Today article was statistically inaccurate while focusing on a few egregious outliers in our profession.

These two articles speak volumes and should serve as another wake-up call to our profession that we are still in a medical war of words.

The first such call-to-arms occurred in November, 2003, at the annual Congress of Chiropractic State Associations (COCSA) meeting in Las Vegas when approximately twenty leaders from different national chiropractic associations, colleges, and publications agreed to unite together in support of a nationwide public relations campaign for promoting chiropractic. Led by Kent Greenawalt of Foot Levelers, the group pledged “to let the experts (the public relations firm) run the campaign and to contribute our money, but not our opinions.”[1]

“We’re here today because each of you, to my knowledge, wants to start your own public relations campaign. And I do, too. However, what we’re doing is not working!” Greenawalt exclaimed.

Today the F4CP website takes credit for “10 years of ongoing success” and last year alone made “31 BILLION positive media impressions.” This equates to 100+ impressions per American adult in one year, but one must ask, how effective has this PR been?

The recent media affront should give us pause to consider what “progress” has really been made over the last decade as we see misguided media attacks, student enrollment remaining low, and our market share allegedly ranging from 10% to 7%.[2] A recent National Center for Health Statistics Data Brief found only 8.5% of Americans used manipulation in 2012.[3]

Ironically, this impasse comes at a time when:

• Back pain alone is the #1 disabling condition in the nation with costs approaching $300 billion in the US,[4]  
• For all musculoskeletal disorders (MSDs), this figure jumps to $850 billion annually,
• Costs approximately $850 billion a year.”[5]
• Accounts for more than 130 million physician visits,
• 10% to 28% of all primary care visits each year, and
• Chiropractic care ranks as a “proven treatment”[6] for acute low back pain

Another study from the Decade of Bone and Joint Disorders by Scott Haldeman, DC, MD, PhD, spoke of the epidemic numbers of back pain sufferers:

• The prevalence of chronic low back pain daily in the general adult population is estimated at 37% (~110 million).
• The 1-year prevalence is 76% (228 million),
• The lifetime prevalence is 85% (255 million), and
• Approximately 20% of sufferers describe their pain as severe or disabling.[7]

If anything, one would think our services should be at an all-time high for our impressive clinical and cost-effectiveness! Instead, we continue to wither on the vine in virtual obscurity. Obviously Kent Greenawalt’s opinion in 2003 still holds true today, “what we’re doing is not working!”

After a decade of effort, isn’t it time to review the results and perhaps give new thought to the future PR effort for this profession? I suggest we begin by analyzing the public’s underlying perspective of our profession.

Indeed, when someone polled on chiropractic once replied, “…I wouldn’t want my daughter to marry one,” you know we have an image problem. [8]

If we are to wrap our heads around this complex issue, let’s look at this problem as a psychologist might. Robert B. Cialdini, PhD, in his book, Influence, the Psychology of Persuasion, gives his insight how public opinion is formed and how to influence it.

According to Cialdini, public opinion is characterized as a “click, whirr” stimulus/response situation. In our case, click on the topic of chiropractic and then, whirr, out rolls the pre-recorded medical tape, that is, the propaganda they’ve learned for nearly a century from the ilk of the AMA’s Committee on Quackery.

Judge Susan Getzendanner at the Wilk v. AMA antitrust trial spoke about the whirr damage done to our reputation by the AMA:

“The activities of the AMA undoubtedly have injured the reputation of chiropractors generally…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.”[9]

Let’s be frank: no other profession has endured the massive defamation campaign that “continues to the present time” as we chiropractors have suffered at the hands of the AMA. It was an illegal albeit effective ploy to destroy a competitor’s image in order to dominate the healthcare market.

It is past time we openly address the medical prejudice against chiropractors and media indifference, an embedded bias I have coined as ‘chirophobia’—the irrational fear, antipathy, contempt, prejudice, aversion, or hatred of chiropractors instilled by decades of medical bigotry.

Similar to any bias like racism, sexism, or homophobia, the public has given little or no conscious deliberation of its accuracy or the dubious origin of this medical muck about chiropractors.  On the rare occasion chiropractic is featured such as the USA Today article showed, it may focus on the outliers, the insurance scams, the egregious patient recruitment methods, or outlandish leaders who chant “the only thing chiropracTIC can’t cure is rigor mortis.”

In order to change this misperception of our profession, as Dr. Cialdini suggests, we must re-program this click, whirr reaction with “social proof” of greater value than medical hearsay, newspaper ads, or testimonials.

In the first half of the 20^th century when spine research was virtually non-existent, the only social proof was word-of-mouth testimonials by satisfied patients, what came to be known as the Wonders of Chiropractic (WOC) ads. This testimonial format continues today at the F4CP with paid celebrities as evident in the ‘meet and greet’ type photo op.

While WOC testimonials have a minor value of influence among the public, alone they cannot achieve a major victory in the media that historically has piled on one-sided articles about our profession until we change the underlying skepticism.

There is a lucrative market to increase our rightful share, we have proven and cost-effective treatments to offer, and a fascinating yet untold story to tell, but before this will happen, we must confront the chirophobia implanted in the court of public opinion. Indeed, it’s past time to dig ourselves out of this hole.

Admissions Against Interest

Let me suggest a new strategy using social proof of higher value—legal, academic, scientific, and media evidence.

Attorney George McAndrews has emphasized to me more than once the value of using “admissions against interest” as he did at the Wilk v. AMA antitrust trial when medical witnesses testified to the efficacy of chiropractic care over medical spine care. Judge Getzendanner noted this irony in her Opinion: “…most of the defense [medical] witnesses, surprisingly, appeared to be testifying for the [chiropractic]-plaintiffs.”[10]

We must use the same tactic with the recent admissions against medical spine care to augment our case—promote the evidence-based guidelines that endorse chiropractic care, the media exposés critical of medical spine care, and the medical experts’ admissions against their own training and treatments.

Fortunately, unlike ever before, the chiropractic profession now has more profound proof with supportive research that began in 1994 when the AHCPR recommended spinal manipulation as a ‘proven treatment’ for acute low back pain in adults.[11]

In 1997, the U.S. Public Health Service conducted another study, “Chiropractic in the United States: Training, Practice and Research,” that admitted “chiropractic has undergone a remarkable transformation” as well as other very positive conclusions:

“Spinal manipulation and the profession most closely associated with its use, chiropractic, have gained legitimacy within the United States health care system that until very recently seemed unimaginable.

“In the past several decades, chiropractic has undergone a remarkable transformation. Labeled an “unscientific cult” by organized medicine as little as 20 years ago, chiropractic is now recognized as the principal source of one of the few treatments recommended by national evidence-based guidelines for the treatment of low-back pain, spinal manipulation. In the areas of training, practice, and research, chiropractic has emerged from the periphery of the health care system and is playing an increasingly important role in discussions of health care policy.”[12]

Despite such glowing reports, the public remains unaware of this growing scientific evidence for our brand of spine care because this information is simply not publicized!

Protecting the Public

Ironically, the main line of defense in the Wilk trial by the medical defendants was their supposedly concern for “patient safety,” a claim the judge didn’t buy.[13]

We might take a lesson from the AMA Committee on Quackery’s claim of protecting the welfare of society from quacks and its use of ‘third-party’ writers to give the appearance that “everybody knows that chiropractic is an unscientific cult.”[14]

Today, we can put the shoe on the other foot with evidence that should convince any objective person in the court of public opinion—not only about the efficacy of chiropractic care, but also concerning the incompetence of medical spine care.

In fact, the huge burden of back pain can be laid at the doorstep of medical spine care that has been dubbed the “poster child of inefficient spine care” by Mark Schoene, associate editor of ^THEBACKLETTER, a leading international spine research journal. Mr. Schoene also warns that “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.”[15]
Do I hear an “amen”?

Medical Spine Incompetence

Not only is the public unaware of the positive research about chiropractic care or the “national scandal” about medical care, it is also unaware of the clinical incompetence of most MDs and DOs in spine care.

Dr. Scott Boden, director of the Emory Orthopedics & Spine Center, admits, “Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders (MSDs).”[16]

Others researchers agree that medical primary care physicians lack training in MSDs,[17] are more prone to ignore recent guidelines,[18] more likely to suggest spine surgery than surgeons themselves[19] and, due to their chirophobia, only 2% of medical PCPs refer to DCs despite our superior training and results.[20]

Perhaps the most ironic surprise showed that 70% of osteopathic graduates failed to attain a passing score on the MSD competency examination.[21] For a profession whose roots began in manipulative therapy, osteopaths today have fallen far from their tree.

The authors of a Johns Hopkins survey concluded, “This discrepancy appears to persist beyond the training years and into the realm of clinical practice.”[22] Certainly this lack of training detrimentally affects physician performance and patient care, but patients are blind to this fact that their favorite family medical PCP is most likely badly informed about MSDs^.[23]

Mr. George McAndrews recently commented on the real quacks in spine care in his article, When the TMA [Texas Medical Association] Looks for Quacks, It Should Search Its Own House, that was published in Dynamic Chiropractic on April 1, 2014, in which he states:

”The AMA, we now know, is interested in one thing: a monopoly over all health care delivery. I could list the many social programs the AMA has been opposed to, but suffice it to say, its goals are not lofty, its intent is not honorable and its methodology is not laudable…

Cost-effectiveness and patient satisfaction, evidence and outcomes are all clearly evident and not contested. The education and training of the DC is superior for NMS conditions, and for anyone to call the DC a quack when the very definition of Quack – a person who falsely pretends to have medical skills or knowledge – is unquestionably the medical physician, whose limited training and skills are obvious from their own tests and studies. This should cause concern about who is calling whom a quack.”

 Scientific Proof

Above the din of chirophobia remains the irony of the medical glass house of spine care built on a flimsy foundation.

The “national scandal” in spine care is fueled not only by the inept training of most MDs and DOs, but evidence critical of the main three medical spine treatments is emerging, such as:

• The Hillbilly Heroin addiction and deaths attributed to the so-called “pill mills” that dispense opioid painkillers like Halloween candy, creating an epidemic of narcotic addiction to the degree that Thomas Frieden, MD, director for the CDC, minced no words when he said, “physicians have supplanted street corner drug pushers as the most important suppliers of illicit narcotics.”[24]
• The expensive, dangerous, and ineffective epidural steroids injections (ESIs) that have never been approved by the FDA for back pain, are no better than placebo, but ignored by pain clinics.[25]
• The tsunami of spine fusions based on a debunked ‘bad disc’ theory. Rick Deyo, MD, MPH, admits, back surgery has increased 15-fold,[26] allthewhile the AHCPR guideline found surgery to be helpful in only 1 in 100 cases of low back problems.[27]
• The ‘bad disc’ diagnosis has been chided by Deyo as irrelevant as “finding grey hair” and dubbed “incidentalomas” since they also occur in pain-free people.[28]
• Researchers now suggest 50-69% of low back and neck pain is pathophysiology—principally joint dysfunction[29],[30]—that trumps over pathoanatomical issues like ‘bad discs’, adroitly described by Donald Murphy, DC, as “red herrings” to scare patients into surgery.[31]

These rocks thrown by researchers at the medical glass house of spine care are the ‘admissions against interest’ that we DCs can use as proof of the medical incompetence in training, theory, and practice treating MSDs.

Indeed, for decades the medical society claimed chiropractic was unscientific, but research since the early 1990s has shown that medical spine care is the actual suspect in this charade of “disrespect.”

Imagine the millions of MSD/back pain patients who have been misdiagnosed, misinformed, and mistreated by MDs and the billions of dollars wasted. We see these failures daily coming into our offices searching for a better way; regretfully, rather than the proverbial last resort, we should be their first choice as the guidelines now recommend.

This medical mismanagement is clearly an equation where bad training + outdated practices + disproved theories + chirophobia + greed = an epidemic of back pain.

If the public understood such critical scientific opinions about medical spine care, instead of the usual click, whirr skeptical response about chiropractic, it could illicit new attitudes, such as:

• “I didn’t know spinal manipulation was a ‘proven treatment’ for acute low back pain in adults.”
• “I didn’t know guidelines now recommend chiropractic care before drugs, shots, and surgery,”
• “I didn’t know only one in 100 back surgeries were necessary.”
• “I didn’t know ‘bad discs’ appear in pain-free people,”
• “I didn’t know epidural shots were never approved by the FDA for back pain,”
• “I didn’t know OxyContin was heroin,”
• “I didn’t know a medical witch hunt had 12,000 chiropractors arrested in the first half of the 20th century,” 
• “I didn’t know in 1930 the AMA jumped into bed with the tobacco industry to fund its war against chiropractors,”
• “I didn’t know the AMA declared war to contain and eliminate the chiropractic profession,”
• “I didn’t know the AMA was found guilty of antitrust activity by a federal court in Chicago,” and, most of all,
• “I didn’t realize chiropractors were right all along.”

Now is the time to drop the other shoe of skepticism about medical spine care—that is, “everybody knows to avoid opioid painkillers, epidural shots, and spine fusions before seeing a chiropractor first.”

Media Proof

The call for reform in spine care is growing not only in the scientific and academic circles, but today we see a continuing flood of news articles revealing the abuse, expense, dangers, and fraud within medical spine care.

The following is a short list over the past few years of recent news articles critical of medical spine care:

• “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies” by P. Waldman, Bloomberg News, Dec. 30, 2010
• “Procedures: Sharp Rise in Complex Back Surgery Among Older Adults,” by Roni Caryn Rabin, New York Times, April 9, 2010
• “An Operation to Ease Back Pain Bolsters the Bottom Line, Too,” by Reed Abelson and Melody Petersen, New York Times, Dec. 31, 2003
• “Surgery May Not Be the Answer to an Aching Back,” by Joanne Silberner, NPR, April 6, 2010
• “Why You Should Never Get Fusion Surgery For Plain Back Pain” by Robert Langreth, Forbes, Jan. 10, 2011
• “600,000 Americans Have Back Surgery Each Year,” TODAY,  September 11, 2012
• “Study Says Back Surgery Often Makes Things Worse,” The Daily Hit, Oct 14, 2010
• “New Study Reveals That Back Surgery Fails 74% of the Time,” SPINE 2011 (Feb 15);36 (4):320–331
• “Back Pain Eludes Perfect Solutions” by Leslie Berger, The New York Times, May 13, 2008
• “Back Pain Is A Complicated Issue” by Karen Ravn, LA Times, April 4, 2011
• “Epidural Steroid Shots Debated Amid Meningitis Scare,” USA Today,  Oct 6, 2012
• “Opioid Painkiller Prescriptions Pose Danger Without Oversight,” by Barry Meier, The New York Times, April 8, 2012
• “Back Surgery May Backfire on Patients in Pain,” by Linda Carroll, MSNBC.COM, Oct. 14, 2010
• “Top Spine Surgeons Reap Royalties, Medicare Bounty,” by John Carreyrou and Tom McGinty, Wall St. Journal, Dec. 20, 2010
• “Medicare Records Reveal Trail of Troubling Surgeries” by John Carreyrou and Tom McGinty, Wall St. Journal, March 29, 2011
• “How Back Pain Turned Deadly” by Elisabeth Rosenthal, The New York Times, November 17, 2012
• “Fee-for-service rewards volume: Our view” The Editorial Board, USA TODAY, July 7, 2013
• “Back Pain: Doctors Increasingly Ignore Clinical Guidelines,” The LA Times, July 29, 2013
• “Patients With Back Pain Often Get The Wrong Treatment,” USA Today, July 29, 2013
• “Worrisome Trends in Back Pain Management,” Medscape Medical News, July 30, 2013.
• “New solutions for long-lingering back pain – CBS News,”  CBS This Morning, July 31, 2013.
• “Former Hospital CEO, Calif. Senator Charged in Insurance Fraud Case,” California Healthline, Feb. 24, 2014
• “Outpatient Back Pain Treatments: Not What the Doctor Should Order,” by Jaime Toro, MD, NEJM, August 20, 2013
• “The Back Pain Most Surgeons Won’t Find,” by Dr. Nick Shamie, CNN.com, September 18, 2013
• “Worsening Trends in the Management and Treatment of Back Pain,” JAMA Internal Medicine, July 29, 2013
• “Hospital Executive Pleads Guilty in Bribes Case,” by John Carreyrou, WSJ, Feb. 21, 2014
• “Rethinking Spine Care” by Jaimy Lee, Modern Healthcare, March 22, 2014
• “Tapping Into Controversial Back Surgeries” by Ben Eisler CBS News April 24, 2014
• “Epidural Corticosteroid Injection: Drug Safety Communication – Risk of Rare But Serious Neurologic Problems,” FDA, April 23, 2014
• “Medicare Data Cast Spotlight On Most Prolific Spinal Surgeons” by Joe Carlson, Modern Healthcare, April 23, 2014

However, due to chirophobia, pitifully few articles mention chiropractic care as the preferred treatment, illustrating that journalists still suffer from ‘professional amnesia’ as we inexplicably remain missing in the media as a ‘proven treatment’ for this pandemic of back pain.

Earned Media vs. Paid Ads

It is past time the public understood why medical spine care is considered a “national scandal” by the editor of ^THEBACKLETTER. As chiropractors, we’ve seen the collateral damage of this scandal—the failed back surgeries, the opioid addicts, and the wasted money and lives. Finally the media is revealing this medical mess.

Never before in this medical war have we had such powerful ammunition with which to fight in this war of words. It’s our turn to drop a few PR bombs on the medical glass house, and rightfully so with the big guns of academic and scientific proof, luxuries we’ve never had before.

Now is the time for the F4CP to diversify its strategy to emphasize “earned media” (aka, free media) that refers to publicity gained through promotional efforts other than advertising.

This approach may actually save the F4CP money since there is no great expense except to hire a publicist to make a concentrated effort to get interviews and articles in the earned media.

Rather than retaining celebrities, I urge the foundation to retain a publicist with a big rolodex to arrange TV or radio talk show interviews with our spokespeople. The F4CP already has potential spokes-people on board such as Gerry Clum Mike Flynn, Tom Klapp, Michele Maiers, Fabrizio Mancini, Carol Ann Malizia, and Bill Meeker. This program can be expanded with other people later as it gets roots.

When I released my book, The Medical War Against Chiropractors, I hired a publicist in Atlanta who arranged interviews on local TV shows, out of state newspapers, and radio talk show stations. I also wrote short stories (no, not me) for lay publications. He charged me less than $1000 per month.

The F4CP should sponsor a program of writers to produce newspaper/magazine articles and electronic, TV, and radio news programming about the new spine science, evidence-based guidelines, and our benefits in order to change the chirophobia of the old medical tape.

The following examples of headlines will draw much more attention in the media and public as well as create the expected push-back from the medical trolls, which would gain added attention in the media.

Here are a few possible pithy headlines (with references):

• “Ruptured Discs Not Always a Pain” (1994 AP news article)

• “Medical Spine Care: Poster Child for Inefficient Care” (The BACKLetter)
• “Chiropractic Care May Re-boot the Brain” (Haavik-Taylor and Murphy)
• “Chronic Back Pain Shrinks the Brain” (Apkarian)
• “Anyone Who Has A Back Surgery Without Seeing A Chiropractor First Should Also Have His Head Examined.” (Robert Mendelsohn, MD)
• “Medicare Accounting Contractor Denies Payment on 65% of Spine Fusions”
• “FDA Report: Epidural Steroid Injections Not Approved for Back Pain”
• “One in 100 Back Surgeries Necessary” (AHCPR guideline)
• “MDs Replace Street Corner Drug Dealers for Narcotics” (CDC news release)
• “Spinal Manipulation Rated ‘Proven Treatment’ by Federal Agency” (AHCPR)
• “Chiropractic Care Vaults from Last to First”  (Tony Rosner testimony before IOM)
• Researchers Confirmed Spinal Manipulation Before Surgery (October, 2010, edition of The Spine Journal)
• “Patients Who First Saw a Chiropractor Underwent Surgery 1.5% Compared to 42.7% of Patients Who Saw Surgeon First” (Keeney BJ et al.)
• “Dartmouth Institute of Health Policy Says 30-40% of Spine Surgeries Unnecessary”
• “Fusion Surgeries Associated with Significant Increase in Disability, Opiate Use, Prolonged Work Loss, and Poor Return to Work Status.” (Nguyen TH, Randolph, DC, et al.)
• Spine Researcher Admits Most Primary Care Providers Inept in Musculoskeletal Disorders.” (Boden)

Such controversy may cause other media outlets to jump on the bandwagon when the chiropractors finally fight back rather than acquiescing to the medical muck.

I believe the more push-back the better as we witnessed with the heated comments about the Forbes article. I feel certain even the busy George McAndrews would like to play in this PR game if his recent comments in the Forbes blog are any indication as well as his past response to Peter Gott, MD, a syndicated medical advice columnist who had written several negative pieces on chiropractic.

Articulate spokespersons will have to be developed to understand that they have 30 seconds to 3 minutes to tell a story. Obviously PR experts are required to coach them in public speaking, polish their delivery, and then have a publicist to make the right media connections in their localities.

This should not be difficult considering Kent Greenawalt, chairman of the F4CP, already has a Foot Levelers Speakers Bureau. Instead of speaking about orthotics, pronation problems, the kinetic chain, etc., it would be invaluable to develop speakers to discuss the poli-sci of healthcare. It would also behoove our profession if the state licensing boards permitted CE credits for topics like poli-sci, history, and the social sciences of healthcare.

Carrying the Torch

George’s brother, Jerry McAndrews, DC, formerly president at Palmer and the driving force as the ICA EVP behind the Wilk et al. v. AMA et al. trial, was also our profession’s most astute spokesman until his death in 2006.

He emphasized to me years ago the need for better social proof to bolster our image:

“I’m praying for the day when our real scientists can say, ‘Chiropractic works, and here’s why.’ Perhaps that’s a challenge for the next wave of chiropractors—those better-educated, evidence-based, bio-mechanists, who will improve our technology and explain the ‘how’ and the ‘why’ of the force behind the matter.”

“Thank heavens we have an increasingly emerging group which collectively says, ‘we’ve had enough.’ This group supports new journals, reads them, begins to reject the smoke of the past, and begins to demand that the language be accurate. Eventually, the misuse of ‘chiropractic philosophy’ will disappear and we will find the ‘philosophy of the science of chiropractic’ in its place. It already sounds stimulating.” [32]

Obviously there is another generation of younger DCs who must be groomed as our future spokespersons who can carry our torch into the 21^st century. The F4CP should sponsor a PR Boot Camp to bring potential writers, speakers, and students together to enhance their knowledge of the issues with sage mentors at hand to get them up the learning curve.

The ideal venue to teach future spokespersons would be the ACC-RAC conference. As stated, “The purpose of the ACC-RAC workshops is to develop the skills of attendees, especially in the areas of research, education, and clinical practice.”

Certainly developing speakers and writers to accumulate and apply the research studies to educate the public as to the best brand of spine care clinical practices would be invaluable and natural application of the scholarly activities already presented at ACC-RAC.

I encourage the F4CP to add to its present PR strategy the development of writers and articulate spokespersons with the help of ACC-RAC in order to disseminate in-depth articles and arrange interviews in the earned media to position DCs as the rightful POE as PSPs for SRDs.

The researchers have prepared our fields, now we need speakers and writers to sow our seeds, mentors to fertilize our crops, and a publicist to spread the good news of our bounty. Indeed, we are the “flowers in the desert” of spine care ready to bloom.

JC Smith, MA, DC, is a 35-year practicing chiropractor, author of The Medical War Against Chiropractors, and he maintains a popular website, Chiropractors for Fair Journalism.