The tragic sinking of the behemoth RMS Titanic was a story of bad leadership to follow warnings and design errors such as the lack of life boats that led to the deaths of 1,524 passengers and crew.
If you will, that tragedy parallels the failure of the medical spine care ship, the Medical Titanic, considering LBP has become the largest healthcare disaster today that could have been avoided if it were not for a string of unfortunate and devious decisions.
The misguided Medical Titanic has led to the number one cause of disability globally of 540 million people who daily suffer with LBP, much of which could have been avoided if chiropractors were at the helm of this wayward medical ship.
After the RMS Titanic collided with an iceberg causing the deaths of 1,514 people of the 2,224 passengers onboard, two commissions of inquiry in the US and UK asked the obvious: “Why didn’t the crew see it coming?”
The crew had received six warnings of sea ice on 14 April but was traveling near her maximum speed and could not turn by the time her lookouts sighted the fatal iceberg. Obviously someone was asleep at the helm when the RMS Titanic collided.
The British inquiry concluded, “What was a mistake in the case of the Titanic would without doubt be negligence in any similar case in the future.”
The same can be said of medical spine care that by today’s standards aboard the Medical Titanic “would without doubt be negligence.” Incredulously, medical spine care continues full steam ahead allthewhile ignoring the warnings to abandon its medical cargo of drugs, shots, and surgery that continue to fall on deaf ears of greedy surgeons and inept MDs in pill mills posing as POE for LBP knowing full well their drugs and fusions are dangerous and disabling.
While the RMS Titanic sank only once, the Medical Titanic is still afloat manned by the same inept crew that continues to victimize millions worldwide as The Lancet panel mentioned in its report, What low back pain is and why we need to pay attention.
Just as the RMS Titanic was considered unsinkable, it will take more than one iceberg to sink the Medical Titanic since this domineering force is commanded by the “most terrifying trade association on earth”— the AMA[i] and manned by the richest crew members in the medical world—the medical spine industrial complex consisting of spine “interventionalists” at pain management clinics and spine surgeons using many low-value, outdated, and dangerous treatments that The Lancet review deemed unseaworthy in its chart:
The Lancet review listed the cargo of major medical treatments — prescription opioids, benzos, epidural steroid injections, spine fusions — at the bottom of its list as either “not recommended” or “insufficient evidence”, yet does anyone believe the Medical Titanic will embrace these warnings and scuttle these dangerous, unnecessary and generally ineffective treatments for 90% of LBP cases?
Okay, stop laughing.
The Lancet panel did mention the medical misinformation by the Medical Titanic with a Key Message:
- widespread misconceptions in the population and among health professionals about the causes, prognosis, and
- effectiveness of different treatments for low back pain,
- including fragmented and outdated models of care
As the warning sirens blare from every new “best practices” guideline, this medical ship plows forth without changing its course despite the multitude of criticism, waste, fraud and abuse. Unfortunately, the Medical Titanic has not yet been sunk to take these “outdated models of care” to a watery grave.
Indeed, there are very important but rarely discussed “widespread misconceptions” and ineffective “outdated models of care” that have led to this pandemic of LBP and the $100 billion spine care cargo stowed on the Medical Titanic.
As we’ve witnessed in the past, the Medical Titanic has ignored every warning to change course; indeed, these spine pirates prefer the present course just the way it is with them in charge making boatloads of money.
Spine surgeons have the highest average compensation in 2013 of all physicians according to Becker’s Spine Review.[ii] Average annual compensation of full-time neurosurgeons included $690,548 in salary plus $138,110 in benefits equates to $828,658 in compensation. Anesthesiologists, many who administer an estimated 9 million epidural steroid injections (ESI’s) annually in the U.S. at pill mills have a median salary of $258,100; it’s easy to see why “needle jockeys” at pill mills are so profitable.[iii]
Lost in the Fog
Just as hundreds of RMS Titanic passengers lost their lives, so have thousands of medical passengers on the Medical Titanic have lost their lives or unalterably changed by opioids, failed back surgery, and a sad life living the quiet epidemic of hopelessness with chronic LBP due to the mishaps of the medical spine crew.
This is not a new criticism, but it is an unheard warning to the public by the mute crew of the Medical Titanic who have given no warnings or apologies for its wake of death and disability.
Instead, we hear “Full Steam Ahead” from the medical pirates in spine care aboard this medical ship. There is simply too much bounty—over $100 billion—to change course now.
What should have been a crowning moment for the stalwart chiropractic sailors who have bravely manned their posts despite stormy weather from organized medicine aimed to cripple our efforts, instead The Lancet panel of reviewers were lost in the fog when they failed to mention the bravery of chiropractors over the past century in this pandemic of LBP to bring help to suffering people.
The Lancet review only reaffirmed the obvious—the overwhelming opioid crisis and ineffective medical spine care—while the main causes of the LBP disaster remain unchanged—in effect, the Lancet panel appeared to be rearranging the deck chairs while the Titanic was sinking.
Despite the preponderance of evidence chiropractors using nondrug and nonsurgical methods would best crew the Medical Titanic, a scan of The Lancet panel’s log will show chiropractic was virtually absent in its review as a capable profession in the war against this pandemic of pain. Not once did the Lancet review recommend a change of command to DCs from the inept medical crew.
Inexplicably the chiropractic profession was ignored by The Lancet review despite being the 3rd largest physician-level profession in the world and clearly the best offering nondrug and noninvasive treatments for the pandemic of LBP.
Obviously the 31 Lancet review panel of experts were asleep at the wheel with this obvious oversight. Without chiropractors worldwide, the pandemic of LBP would have increased exponentially. With chiropractors at the helm this pandemic of pain could be reversed if passengers had full access to chiropractic care—that should have been the Key Message touted by the panel.
Indeed, if not DCs, who’s better qualified by experience, education, and clinical effectiveness as POE for LBP?
Wake of Wreckage
Long before the opioid crisis and LBP pandemic were declared in the last few years, famed orthopedist Gordon Waddell in 1989 warned of the prevailing doom of the Medical Titanic:
“Low back pain has been a 20th century health care disaster… back surgery has been accused of leaving more tragic human wreckage in its wake than any other operation in history.”[iv]
Undoubtedly his condemnation of back surgery “leaving more tragic human wreckage in its wake” shows no sign of diminishing in the 21st century disaster either. More than 480,000 spinal fusion surgeries are performed each year in the United States and, between 2001 and 2011, spinal fusion surgeries increased by more than 70%. According to an article, Spinal Fusion Surgery: On the rise but often not necessary:
“Experts consulted for this study are concerned that the high number of spinal fusion surgeries may be also due to an increased number of unnecessary procedures being done for low back conditions that do not warrant spinal fusion.”
The Medical Titanic also had many clear warnings to change course over the past 25 years that have been ignored:
- In 1976, renowned medical educator John McMillan Mennell, MD, spoke of the value of spinal manipulation during his testimony at the Wilk trial:
“If you don’t manipulate to relieve the symptoms from this condition of joint dysfunction, then you are depriving the patient of the one thing that is likely to relieve them of their suffering.”[v]
In 1992 Dr. Mennell published his book, The Musculoskeletal System: Differential Diagnosis from Symptoms and Physical Signs, in which he described the loss of joint play as a major cause of pain and joint manipulation as the best correction:
Loss of play in synovial joints is mechanical diagnostic entity designated ‘joint dysfunction,’ and this is a mechanical diagnosis of a cause of symptoms. It is common in any synovial joint anywhere in the system. To correct a mechanical fault it is logical to seek a mechanical form of treatment. This is joint manipulation.[vi]
Obviously his analysis flies in the face of the panel’s “nonspecific” cause of LBP, certainly not an explanation to hang your hat on.
“For nearly all people presenting with low back pain, the specific nociceptive source cannot be identified and those affected are then classified as having so-called nonspecific low back pain.”
Maybe the source “cannot be identified” by primary care physicians, PhDs, or academic elitists on the panel, but chiropractors have identified and treated such conditions for over a century with great results.
This oversight may be explained by the lack of a classic chiropractor or manual therapist who could have educated the panel of a mechanical explanation, whether designated as the classic chiropractic vertebral subluxation (Langworthy, Smith, Paxson, Palmer), osteopathic lesion (Still), joint play (Mennell), manipulatable lesion (Haldeman), joint complex dysfunction (Seaman) or segmental buckling (Triano).
More warnings have come from other notables:
- In 1992 Paul Shekelle, MD, director of the RAND study on low-back pain and chiropractic care:
“To say that there is no scientific proof [of spinal manipulation], I would say that there’s considerably more randomized controlled trials which show benefit for this than there is for many other things which physicians and neurosurgeons do all the time.”[vii]
- In 1994 the Agency for Health Care Policy and Research (AHCPR), under the guise of the US Public Health Service, assembled a national group of interdisciplinary spine experts to formulate the “best practices” entitled “Acute Low Back Pain in Adults” that recommended spinal manipulation as a “proven treatment” along with NSAIDs and ice/heat to be used before drugs, shots and surgery:[viii]
“Manipulation, defined as manual loading of the spine using short or long leverage methods, is safe and effective for patients in the first month of acute low back symptoms without radiculopathy. For patients with symptoms lasting longer than 1 month, manipulation is probably safe but its efficacy is unproven. If manipulation has not resulted in symptomatic and functional improvement after 4 weeks, it should be stopped and the patient reevaluated.”
The section on Spinal Fusion from the AHCPR’s Clinical Practice Guideline clearly summarized the research critical of fusions:
There appears to be no good evidence from controlled trials that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fractures or dislocation….Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.[ix]
Not only were chiropractors virtually ignored by the panel, medical physician incompetence in spine care was also minimized by the panel although many spine experts have been highly critical.
- In 1998 Richard Deyo, MD, MPH, warned of inept MDs:
“Calling a physician a back-pain expert, therefore, is perhaps faint praise—medicine has at best a limited understanding of the condition. In fact, medicines’ reliance on outdated ideas may have actually contributed to the problem.”[x]
- Spine journal editor and Lancet panelist, Mark Schoene also was blunt in his assessment of medical spine care:
“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.” [xi]
Mr. Schoene also makes the case primary care medical practitioners are actually dangerous to patients:
“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—primary care MDs.” [xii]
- The National Pain Strategy also mentioned MDs are ill-prepared to manage chronic pain:
“Physicians are not adequately prepared and require greater knowledge and skills to contribute to the cultural transformation in the perception and treatment of people with pain.”[xiii]
In 1990, MRI researcher Scott Boden, MD, now director of the Spine Center at Emory University, found “bad discs” in pain-free people confirming early suspicions that herniated, bulging, or degenerated discs were coincidental and not the holy grail of back pain causation that require fusion. [xiv],[xv]
- Dr. Boden also confessed, “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”[xvi]
Certainly to encourage patients to seek medical primary care providers as The Lancet panel suggested is to turn the fire station over to the arsonists.
Key Lost Messages
Two commissions of inquiry in the US and UK asked the obvious: “Why didn’t the crew see it coming?” The same can be asked why this pandemic of LBP developed in the first place.
The Lancet Summary on LBP did mention important Key Messages worth noting but failed to explain why this LBP disaster occurred and, in effect, continues to this day:
“However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery.” [xvii]
In other words, wasteful low-value medical care continues unabated while high-value chiropractic and other hands-on front-line treatments remain secondary.
This Summary was spot-on, but again failed to offer an explanation how the “gaps” in spine care developed since the panel made:
- no mention of the medical monopoly—the AMA, NASS, and Big Pharma—dominating the spine care market place, as one of the largest lobbyists on Capitol Hill, as well as dominating the media as we’ve seen with neurosurgeon Sanjay Gupta at CNN,
- no mention of the 100+ year war against chiropractors,
- no mention MDs are inept in MSDs,
- no mention MDs are the source of the opioid crisis,
- no mention of the debunked ‘bad disc’ diagnosis,
- no mention of the lack of Informed Consent by MDs to inform patients of alternatives,
- no mention of the dire lack of referrals to DCs, and
- no mention DCs should be the POE for LBP as some studies have suggested (2010 Tennessee BCBS report, 2013 internal analysis by Optum Health).
Chiropractors to the Rescue
Perhaps the omission of the benefits of chiropractic care by the panel was to be expected considering not one American or classic chiropractic practitioner was included on the panel; indeed, I doubt this panel will ever be accused of having full diversity.
Unless one has lived the “chiropractic experience” just as, for example, living the “black experience,” people cannot imagine what it is to have our perspective. Indeed, being the “black sheep” in the medical world gives a DC a unique perspective to the origins of this opioid and LBP crisis.
Indeed, how can any panel on LBP not include one historian, sociologist or poli-sci academician to explain this cultural iatrogenesis of pain in historical, political, and economic terms? If the panel thinks promoting EBM alone will change the course of the Medical Titanic, it is more naïve than I envisioned.
Certainly LBP is a huge global burden, but imagine how much worse it would have been without the help of the chiropractors worldwide who have fought to bring our nondrug, noninvasive methods to the world while fighting the “most terrifying trade association on earth”—the AMA—the most shocking untold story in healthcare.[xviii]
For example, few people realize the price chiropractors paid in the first half of the 20th century when 12,000+ chiropractors were arrested over 15,000 times.[xix] DCs have never been given credit for fighting the good fight against medical onslaught of drugs and surgery. The same can be said of every country where medical freedom does not exist, such as the witch hunt Down Under.
Fortunately dedicated chiropractors persist to keep this effective healing art alive despite the medical aggression, political dirty tricks, academic sabotage, and the immense defamation campaign against our profession.
How could these important historical factors be overlooked by the panel if it wanted to understand fully the causation of this medical mess in spine care?
Backstory of LBP
For some unknown reason, the Lancet reviewers never broached the backstory to explain what created the “outdated models of care” that have led to the present Pharmageddon and the scourge of failed back surgery.
Foremost in the history of chirophobia—the medical bias against chiropractors—was the illegal boycott and the defamation of chiropractors as revealed in the Wilk et al. v. AMA et al. case led by attorney George McAndrews. The boycott of chiropractic care in hospitals, barriers to patient access in insurance programs, and the smear campaign of chiropractic taught in medical schools perpetuated the “widespread misconceptions” that remain virtually in tack today.
Undoubtedly the most devious “widespread misconception” was the defamation campaign conducted by the AMA Committee on Quackery to soil the reputation of the entire chiropractic profession as “dangerous quacks” in an “unscientific cult” that was never proven in court but left an indelible blemish on the face of our entire profession.
Even famed nationally-syndicated newspaper columnist Ann Landers was used by the AMA to spread misinformation about the chiropractic profession.[xx] In deposition for the Wilk trial, Landers admitted she had been paid by the AMA to write articles condemning chiropractic as an “unscientific cult.”
Author William Trever outlined the ill-begotten propaganda strategy used by the AMA’s Committee on Quackery to destroy the reputation of the chiropractic profession:
Time and time again the AMA’s Merchants of Misinformation have subverted the truth for their own fascist ends. Using these tactics to “build up a case” against chiropractic they have taken objective reports, studies, and individual opinions in favor of chiropractic and reversed them into what appears to be anti-chiropractic views coming from many “non-medical” sources. Done enough, this tactic would give the appearance that “everybody knows that chiropractic is an unscientific cult.”[xxi]
In the court Opinion at the conclusion of the Wilk antitrust trial in 1987, Judge Susan Getzendanner wrote of the damage inflicted upon chiropractors and described the conspiracy as “systematic, long-term wrongdoing, and the long-term intent to destroy a licensed profession.”[xxii]
“By labeling all chiropractors unscientific cultists, injury to reputation was assured by the AMA’s name-calling practice,” which was exactly the goal of the medical profession—to defame its main competition in the court of public opinion to invalidate our expertise and to capture the healthcare marketplace.
After the trial, these medical foes were unrepentant believing the court decision was wrong according to a 1991 article, Chiropractors vs. AMA, in The Chicago Reader:
“My impression is that Judge Getzendanner’s decision was an emotional one,” says William Tabor, former house counsel for the AMA. “I think Judge Getzendanner thought with her glands rather than her brain. I think she did not have a very good understanding of medical ethics. She grasped onto every piece of evidence that was negative. The theory of chiropractic is still unscientific, and it always will be. It’s baloney and no matter how thick you slice it, it’s still baloney. She was never interested in understanding that. I think she looked at it on a visceral level, ‘Here’s this huge organization trying to destroy these poor chiropractors.’ I think her decision was erroneous.”[xxiii]
“He sounds like a sore loser,” remarks Getzendanner, now in private practice. She categorizes Tabor’s comments as “pretty sexist.” “All the emotional play in the case was by the defense’s lawyers. They really overplayed it with horror stories about how bad chiropractic was–chiropractors trying to treat brain tumors with cranial manipulation, that sort of thing. But that wasn’t the issue, and I finally told them to cut it out.”
The issue, she says, was the conspiracy by the AMA to “contain and eliminate” chiropractic. “They didn’t deny there was a conspiracy. That is not in dispute. The stated goal of the Committee on Quackery was to destroy chiropractic, and they worked real hard at it for many years. The AMA’s entire case was that it had ended its unlawful conduct in 1980, when they eliminated the principle that said it was unethical for an MD to associate professionally with chiropractors.
At the Wilk trial victory, the judge ordered the AMA to announce in the JAMA it was okay for MDs to work with or refer to DCs if they so choose and the AMA was required to send a copy of the Permanent Injunction Order to each of its current members.
There was no mea culpa by the AMA and no tabula rasa to restore the reputation of chiropractors; small reparations were paid to the chiropractic colleges, but no one went to jail and the AMA experienced relatively little punishment other than paying legal fees and a $300,000 donation to the Kentuckiana Children’s Center.
This trial verdict was simply the cost of doing business for this Medical Titanic after inflicting years of irreparable harm to the reputations of its main rivals, chiropractors, and the Medical Titanic continued on course reeking havoc in the lives of millions.
As well, the fascinating evidence about the superiority of chiropractic over medical care that came out at trial was simply swept under the medical rug and went unmentioned in the press,
Moreover, the AMA’s main defense of “patient safety” to justify its boycott of chiropractors was never proven. After years telling the public and press that chiropractic was a dangerous unscientific cult, the AMA could not prove it.
In fact, Mr. McAndrews noted in his closing statement, “… they haven’t brought in a patient. You’d think if all of these patients have been injured, some would come in here and say they were taken by a chiropractor. Not one walked through the door.”[xxiv]
The judge also ruled, “The AMA did not, during the entire period of the boycott, have reason to hold that view. It is clear that there were some therapeutic benefits of chiropractic that the AMA knew about.”
Once the “patient safety” issue was invalidated, the judge admitted the medical war was primarily a turf battle. “Absolutely,” Judge Getzendanner later confessed. “Chiropractors compete with doctors. There’s no question about it: it’s basic competition.”[xxv]
Considering the estimated $700 million in lost revenues to chiropractors during the AMA boycott from 1962 to 1980, the legal costs and minimal fine were just the cost of doing business for the AMA.
Moreover, the damage continues today considering chirophobia continues in the court of public opinion and in the mainstream medical media because the AMA and its media mouthpieces have “never made any attempt to publicly repair the damage the boycott did to chiropractors’ reputations” as Judge Getzendanner said.
Sadly, over 25 years after the landmark Wilk trial victory, this slander remains fait accompli. The public was never informed of the magnitude of the character assassination of the chiropractic profession nor has the public been aware of the superior results of chiropractic care over medical spine care. Sadly, the chiropractic profession remains virtually adrift riddled with outdated biased opinions that have never been repaired in the sea of public opinion.
These are the “widespread misconceptions” that The Lancet panel failed to examine—this remains the elephant in the room the panelists are too blind to describe. These are the untold stories the public and press need to hear before they will understand why LBP has become the leading disability in the world and why chiropractors are best equipped to help.
In my two books, The Medical War Against Chiropractors and To Kill a Chiropractor: The Media War Against Chiropractors, I discuss how these “widespread misconceptions” developed to mislead the public to “outdated models of care” resulting in immeasurable costs, deaths and disability worldwide.
In my next article, Minimally Invasive or Maximally Deceptive, I will discuss the latest “widespread misconceptions” in spine care—TV ads for laser spine surgery.
[i] M Mayer, “The Rise and Fall of Dr. Fishbein,” Harper’s Magazine, 199/1194 (Nov. 1949): 76
[ii] Neurosurgeon Annual & Hourly Pay: 8 Statistics, by Bob Herman, Becker’s Spine Review, May 6, 2013.
[iv] G Waddell and OB Allan, “A Historical Perspective On Low Back Pain And Disability, “Acta Orthop Scand 60 (suppl 234), (1989)
[v] Transcript of testimony of John McMillan Mennell, M.D., Wilk v AMA transcript pp. 2090-2093.
[vi] John McMillan Mennell, The Musculoskeletal System: Differential Diagnosis from Symptoms and Physical Signs. Aspen Publications, 1992, p. 22.
[vii] Shekelle, P. et al. RAND Corp Report, “The appropriateness of spinal manipulation for low-back pain,” Santa Monica, Calif. 1992.
[viii] Bigos et al. U.S. 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)
[ix] S Bigos, ibid. p. 90.
[x] Deyo, RA. Low -back pain, Scientific American, pp. 49-53, August 1998.
[xi] Why Should the National Pain Strategy Be MD-Centric? BackLetter: February 2016 – Volume 31 – Issue 2 – p 16
[xii] http://iom.nationalacademies.org/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx, pp.5.
[xiii] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28 (2003):524-525.
[xiv] 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.
[xv] MC Jensen, MN Brant-Zawadzki, N Obuchowski, MT Modic, D Malkasian, and JS Ross, “Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain,” NEJM, 331/2 (July 14, 1994):69-73
[xvi] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28 (2003):524-525.
[xvii] Prevention and treatment of low back pain: evidence, challenges, and promising directions, March 21, 2018, The Lancet
[xviii] M Mayer, “The Rise and Fall of Dr. Fishbein,” Harper’s Magazine, 199/1194 (Nov. 1949): 76
[xix] Russell W Gibbons, “Go to Jail for Chiro,” Journal of Chiropractic Humanities 4 (1994): 61–71.
[xx] Deposition of Ernest K. Howard by G McAndrews, (Dec. 15, 1980):1053.
[xxi] W Trever, “in the Public Interest,” Scriptures Unlimited, Los Angeles, Calif., (1972):11
[xxii] Associated Press, “U.S. Judge Finds Medical Group Conspired Against Chiropractors,” New York Times (1987)
[xxiv] G McAndrews closing argument, ibid. p 7076-88.
[xxv] Bryan Miller, Chiropractors vs. AMA, Chicago Reader ,June 27, 1991