Evidence-Based Medicine: Where Art Thou?

Three Unwise Monkeys

       The Institute of Science in Medicine (ISM) is a dangerously deceptive organization that hides behind an illusion of medical watchdogs to “protect the public from the predations of anti-, non-, and pseudo-scientific practices.”

Of course, the ISM alone determines what qualifies one method as “pseudo-scientific practices” and the others as “scientific.” Just like its predecessors—the Medical Mussolini, the CoQ, and Stephen Barrett—these current ISM GoodFellas continue to take cheap shots at chiropractors allthewhile ignoring the medical spine care problems.

Certainly the most glaring problem with ISM is that it is not its role to act as watchdogs since this is a governmental issue within each state. No one has endowed ISM to act as such, but the AMA has never subjected its power to any governmental agency in its quest to remain the medical monopoly.

Another troubling concept in the ISM mission statement is the fact ISM purports to be scientific and “evidence-based” despite the obvious non-scientific nature of much of medicine. Indeed, how scientific are deaths and addictions to Oxycotin or the 130 deaths per million from unnecessary spine fusions or the super germs created by the overuse of antibiotics? Don’t get me started on the problems of medical care.

The father of evidence-based healthcare, David Eddy, MD, might like to partake in this conversation considering Eddy has been critical of “Medical Guesswork” as published in Business Week.[1]

Eddy believes only 15% of medicine is based on evidence while more optimistic ethicists claim no more than 25% of medical care is based on actual science, suggesting 75% of medical care is baseless.

In fact, the ISM should come clean and admit the vast majority of medical care is not evidence-based as Eddy suggests and as the NZ Commission found in regards to spine care.

The 200+ various treatments available for low back pain only compound this dilemma.^[2]  To make matters worse for patients, surgeons often have a conflict of interest, many doctors ignore evidence-based guidelines, some physicians practice outdated methods, and many still hold a bias against what is proven to be effective—spinal manipulative therapy.

Indeed, where is the ISM’s critical analysis of medical spine care? Instead, it appears the ISM’s tactic is to scare the public about the supposed danger of SMT causing stroke rather than discussing the inappropriate medical spine care.

I doubt the GoodFellas at ISM really want to juxtapose the hundreds of thousands of deaths annually from medical mistakes to the paltry harm caused by chiropractic. If that’s the game they want to play, I will gladly recite the dangers, costs, and ineffectiveness of medical spine care, specifically opioids, NSAIDs, ESIs, and spine surgery based on the outdated disc theory.

Certainly the new guidelines for acute and chronic LBP treatment haven’t slowed down the use of these questionable medical treatments. As proof of this absurdity, spine pundit, Rick Deyo, MD, MPH, noted, “The most complex type of back surgery has increased dramatically between 2002 and 2007 with a 15-fold increase.”^[3]

According to Dr. Deyo, “People say, ‘I’m not going to put up with it,’ and we in the medical profession have turned to ever more aggressive medication, narcotic medication, and more invasive surgery.”^[4]

Where is the chorus of disapproval from the GoodFellas at ISM when their own colleagues so badly ignore the evidence in spine care?

Imagine if chiro care (SMT) had suffered the same poor outcomes as drugs, shots, and surgery in the research studies and were not recommended in the guidelines, and yet increased by 15-fold. Certainly the ISM would be all over the news media crying their tune of “pseudoscience.”

Yet, when it happens in the medical profession, the silence is deafening. Indeed, in my new book, The Medical War Against Chiropractors, I discuss in depth this paradigm shift in spine care and the battle being fought by organized medicine to avoid this inevitable change.

The Three UnWise Monkeys

Apparently the GoodFellas seem more like the Three (Un)Wise Monkeys than watchdogs. The “See no evil, hear no evil, speak no evil” by definition is commonly used to describe someone who willfully ignores the immorality of an act in which they are involved.

The GoodFellas at ISM certainly suffer from the “see no evil” syndrome when they turn a blind eye to the spine research supporting chiropractic care, they “hear no evil” when the advice of spine researchers and guidelines against drugs, shots, MRIs, and spine surgery fall on deaf ears, and they “speak no evil” when they become tongue-tied when their own Fellas practice non-evidenced-based methods.

These omissions, of course, do not come as a surprise to other scientists who are painfully honest about the shortcomings of medical spine care.

“It’s amazing how much evidence there is that fusions don’t work, yet surgeons do them anyway,” said Sohail Mirza, a spine surgeon who chairs the Department of Orthopaedics at Dartmouth Medical School. “The only one who isn’t benefiting from the equation is the patient.”^[5]

Richard Deyo, MD, MPH, concludes such “proliferation of risky and expensive practice beyond reasonable supporting evidence is commonly mentioned as a fundamental failing of medical practice in the United States.”^[6]

Actually, this is not new criticism of spine surgery. On June 9, 2006 the CBS Evening News aired a segment, “Attacking Rising Health Costs,” stating 30-40% of spinal fusions surgeries were unnecessary. The problem, according to Dr. Elliott Fisher of The Dartmouth Institute of Health Policy, is that patients are not given good information to make an “informed consent” decision as to alternatives like chiropractic care or the inherent risks of medical procedures.

Author Jerry Groopman, MD, wrote in The New Yorker magazine that his orthopedist, knowing perfectly well of the controversial nature of spine fusions, nonetheless admitted: “If I don’t do them, they’ll go around the corner and the other surgeon will.”^[7]

So, where is the chorus of caution from the ISM GoodFellas about medical spine care when Drs. Deyo, Mirza, Fisher, and Groopman, among many experts, suggest back surgeries are treatments that only profit the surgeon (as well as hospitals, MRI vendors, druggists) and not the patient?

Medical Mistakes

It’s hard to keep a straight face when I read that the ISM wants to police healthcare for “safe and effective medical treatments.” May I suggest they first clean up their own house that is riddled by thousands of iatrogenic mistakes and deaths before they attack chiropractic?

Lest I remind ISM of infamous study, “Deaths After Chiropractic: A Review Of Published Cases,” by Edzard Ernst of the Medical School at the University of Exeter, that once again raised the level of fear over chiropractic care when he noted that “Twenty-six fatalities were published since 1934 in 23 articles.”[8]

Considering this covers 76 years and equates to 0.34 deaths per year, instead of sounding an alarm to scare people as Ernst attempted, he should have praised chiropractic care for its obvious safety since this is an extremely low rate in comparison with equivalent medical methods for the same diagnostic condition.

Many public healthcare experts agree with Barbara Starfield, MD, MPH, from Johns Hopkins School of Hygiene and Public Health, who in 2000 found 225,000 medical iatrogenic deaths per year constitutes the third-leading cause of death in the U.S., after deaths from heart disease and cancer.[9]

Dr. Starfield’s estimate has probably more than doubled since 2000. In her article in JAMA, “Is US health really the best in the world?” her answer was a resounding “no.” She also admits that “20% to 30% of patients receive contraindicated care.”

Dr. Starfield’s report was supported by another study in 2003 that meticulously reviewed the statistical evidence and their findings were absolutely shocking.[10] This paper, “Death by Medicine,” by Gary Null, PhD, Carolyn Dean MD, ND, Martin Feldman, MD, Debora Rasio, MD, and Dorothy Smith, PhD, presents compelling evidence that today’s medical system frequently causes more harm than good.

This fully referenced report shows the number of people having in-hospital, adverse reactions to prescribed drugs to be 2.2 million per year. The number of unnecessary antibiotics prescribed annually for viral infections is 20 million per year. The number of unnecessary medical and surgical procedures performed annually is 7.5 million per year. The number of people exposed to unnecessary hospitalization annually is 8.9 million per year.

The most stunning statistic, however, is that the total number of deaths caused by conventional medicine is an astounding 783,936 per year (recall this was in 2003, which means this figure is undoubtedly much larger today).

It is now evident that the American medical system is the leading cause of death and injury in the US. By contrast, the number of deaths attributable to heart disease in 2001 was 699,697, while the number of deaths attributable to cancer was 553,251.

I might add this mistake-laden system is especially true for medical spine care methods that are now deemed by researchers and guidelines as outdated, often ineffective, certainly addictive, and very expensive.

Watchdog or Blind Mice?

So, if the watchdog members of ISM are “evidence-based” as they proclaim publicly, perhaps they ought to take a closer, “fair and balanced” look at the evidence for/against both medical and chiropractic spine care methods.

I daresay the ISM’s constant slander against chiropractors is a façade to distract the public’s and media’s attention from their own deplorable situation. A cursory examination will explain why the war against chiropractors is so “remorseless and unrelenting,” mainly because back surgery is big business that wants no competition.

Despite the call for restraint in spine fusion surgeries, a 2006 study indicated the shocking cost increase of 500 percent between 1992 and 2002 from $75 million to $482 million.^[11] Dr. Deyo mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.”^[12]

Finally, an honest physician admits the truth! Dr. Deyo must be as popular at NASS conventions as Chief Justice Roberts is now at Republican cocktail parties after he upheld Obamacare.

The shocking fact is average annual salary of a spine surgeon is now the highest paid of all doctors at $806,000 according to Bloomberg News.^[13] This salary does not include the royalties and commissions paid 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.”^[14] Remarkably, the pedicle screws inserted in a spine fusion cost $100 to manufacture, but retail for $2,000.

The ISM’s concern for “safe and effective medical treatments” is admirable, but where is the concern about medical spine care methods like Oxycotin, ESIs, and spine fusions, all very unsafe, addictive, costly, and ineffective methods decried by spine experts?

Not only are patients forced into these risky drugs, shots, and spine surgery, in most hospitals they are denied the best spine care as recommended by the guidelines. Any hospital that refuses to have a chiropractor on staff should hang out a full disclosure sign in its lobby: “The least expensive and most effective spine care for 85% of back pain cases is not available in this hospital.”

Perhaps the GoodFellas at ISM might warn the public about the dangers of medical spine care, starting with the 14,800 deaths from Oxycotin in 2010 or the 16,500 deaths from NSAIDs annually.[15]

Other recent investigations into the dangers of spine surgery were just as shocking:

• Eight hundred twenty-two (87%) patients had at least one documented complication. There were 14 mortalities during the study period. The rate of intraoperative surgical complication was 10.5%. The incidence of postoperative complication was 73.5%.[16]
• Thirty-one deaths were reported for an overall rate of 1.3 per 1000 or 130 deaths per million. Respiratory complications were the most common cause of mortality (13 cases). Twenty-six of the deaths occurred in children undergoing scoliosis correction.[17]
• Pain medications are involved in more than 20 percent of deaths occurring in the years after spinal fusion surgery for low back pain, reports a study in the April 1, 2009 issue of Spine.
• In the 105 articles reviewed, there were 79,471 patients with 13,067 reported complications for an overall complication incidence of 16.4% per patient.[18]
• Complications from epidural steroid injections include respiratory arrest, epidural hematoma, headaches, spinal cord infarction.[19]

Obviously these serious mistakes from medical spine care are never mentioned by ISM. Despite the huge discrepancy in medical mistakes compared to chiropractic errors, the GoodFellas are quick to use Chicken Little articles to incite mass hysteria by chanting, “Chiropractors cause strokes, chiropractors cause strokes,” allthewhile hiding the fact that there is a greater likelihood of sustaining a stroke at a hairdresser’s salon, in a dentist’s office,[20] or even a greater chance of being hit by lightning than at the hands of a chiropractor.

Indeed, where is the outcry by the ISM about the tsunami of addictive drugs, ineffective epidural shots, expensive MRI scans looking for “incidentalomas,”[21] and dangerous spine surgery based on an outdated disc theory[22]?

The Tide is Turning

The evidence for chiropractic care is mounting. A 1998 editorial in the Annals of Internal Medicine noted that “spinal manipulation is the treatment of choice.”^[23] In 2007 a Joint Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain also recommended spinal manipulation for acute, sub-acute, or chronic low back pain.^[24] Surprisingly, the North American Spine Society also recommends spinal manipulation before surgery.^[25]

So, how should we consider those MDs who refuse to refer to DCs, but still prescribe addictive narcotics, epidural steroid injections that are no more effective than placebo^[26], and do hundreds of thousands of expensive MRIs and spine surgeries based on the disproved disc theory?

Are they quacks or criminals or simply inept?

Even those physicians with a special interest in low back pain were found to be more likely to believe in outdated concepts such as narcotics, complete bed rest, and avoidance of work for acute low back pain—concepts now regarded as inappropriate.

Oddly, there were no important differences in back pain beliefs between those with and without a special interest in musculoskeletal medicine.[27] It appears that any MD with an interest in back pain can hang out a “pain clinic” shingle even when poorly trained in this area. And there certainly is a growing market for addictive opioids in this country as we’ve seen lately with the abundance of “pill mills.”

The Bishop study published in Spine scored the content of the family physician-directed care and found it to be “highly guideline-discordant.” The three studies by Bishop et al. provide an excellent illustration of the slow pace of implementation of evidence-based spinal care into primary care settings.

“Typically, the family physician-based care involved excessive use of passive therapies such as massage and passive physical therapy, excessive bed rest, and excessive use of narcotic analgesics,” said Paul B. Bishop, DC, MD, PhD, Clinical Associate Professor in the Department of Orthopaedics at University of British Columbia. [28]

Despite this lack of education, the average MD still poses as an expert to patients. As attorney George McAndrews mentioned during the Wilk trial, this typifies a quack:

They use the definition of quackery: somebody who pretends to knowledge they do not have. Chiropractors that pretend to medical knowledge are quacks. And medical physicians who pretend to universal knowledge of human anatomy and biomechanics on this record should be called quacks if the definition is: somebody who pretends to knowledge they don’t not have. That’s quackery. We all agree on that. [29]

 Unfortunately, medical quacks are still prescribing ineffectual medications, ordering expensive MRIs looking for “incidentalomas,” only then to refer to a spine surgeon. If and when patients ask for an opinion on chiropractic care, many are discouraged or even ridiculed for asking. Typically, the usual MD-patient encounter is one of a misdiagnosis, mistreatment, and misinformation about options to the best care available—specifically, chiropractic care.

This is the real dilemma in evidence-based spine care today since the public has no idea most MDs are inept in spine care treatments and still recommend outdated methods.

Deyo commented on this dilemma: “…we’ve witnessed disturbing practices that seem designed to maximize someone’s income, regardless of whether there was benefit or harm to patients.”^[30]

Now we can understand why Gordon Waddell, MD, once said:

“Low back pain has been a 20th century health care disaster. Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem…It [back surgery] has been accused of leaving more tragic human wreckage in its wake than any other operation in history.”^[31]

Certainly any investigation must conclude medical spine care is economic-based, not evidence-based nor ethics-based.

Zombie GoodFellas

The ethical questions in this matter may be best explained by medical ethicist Bruce G. Charlton, MD, who suggests, “Old-style science had many faults, but deliberate and systematic misrepresentation was not one of them”^[32]

His point is well taken considering the vast twisting of the truth about the danger of chiropractic care. The cheap shots taken by ISM members in the media illustrate the “deliberate and systematic misrepresentation” of facts concerning SMT and the failings of medical spine care.

This pattern of willful ignorance and unwarranted malice toward chiropractic by ISM resembles “zombie science,” according to Charlton, who defines it as “a sinister consequence of evaluating scientific theories purely on the basis of enlightened self interest.”^[33]

I daresay if anything the AMA does well is to protect its self-interest by defaming competition, ignoring damning evidence about its own medical methods of drugs, ESIs, and spine surgeries, and soiling the marketplace with Chicken Little journalism.

Lastly, the ISM’s mission statement to “discuss the need for public policies which promote a scientific standard for safe and effective medical treatments…” is a challenge eagerly accepted by chiropractors. I really don’t think the ISM GoodFellas want to go there, but I’m willing to debate these issues in a frank discussion.

If Harriett Hall and other Fellas in ISM are as keen on evidence-based spine care as I am, they will soon come to love chiropractic care. And if they ever were to experience a good spinal adjustment, they will love our care as much as the millions of patients who use our care despite the medical propaganda.

We will certainly become fast friends after discussing the multitude of research and guidelines (AHCPR, Manga, UK BEAM, NICE, NASS, and BJD) that now support chiro care for the epidemic of back pain.

It’s past time to stop with the medical Chicken Little journalism, to stop with the Three Unwise Monkeys style of viewing science, and it’s time to stop the zombie medicine that has created this epidemic of poorly treated back pain.

Jay Triano, DC, PhD, laid down a similar gauntlet during the FSU fiasco that the ISM GoodFellas helped to sabotage that I will repeat: “The chiropractic profession as a whole…is ready to step up to the plate and to let its belief systems be tested scientifically. Let the chips fall where they may.’’ ^[34]

It’s time to debate this issue on national television to crack this nut of medical bigotry.