Peanut Butter in the Gas Tank

peanutbuttergastank

People amaze me. Honestly, I am always surprised by many people’s consistent failure to leverage logic in a situation. Here’s an example: A patient had a lumber disc issue three years ago. After seeing several other practitioners, epidural steroid injections and physical therapy all failed to produce desirable results, a friend of the patient suggested he see me. A few properly directed treatments of flexion-distraction and long axis decompression went a long way to quickly dissipate this patient’s disc pain. We were both quite happy with his recovery.

Fast forward to now; three years later. The patient again comes to me with disc pain. When I asked when it began, the patient tells me it started 6 months ago and he went through physical therapy, medications and more injections before returning to me. I was stunned. Chiropractic treatment worked so well for his disc pain in the recent past, why would he not seek my help immediately after a similar flare up?

I equate this form of illogical thinking to putting peanut butter in one’s automobile gas tank. After all, the past hundred times I put gasoline in my car, it ran as it was intended. But this time, I am going to put peanut butter in the tank instead of gasoline hoping for a better result. Huh?

The old adage that people who do what they’ve always done will get what they have always gotten is usually used to illustrate the negative consequences of stagnation. However, if you are satisfied with the results of what you have done in the past, continuing with that same strategy just makes good sense.

 

Brett Kinsler is a chiropractor in Rochester who treats disc injuries in a way that works. If it didn’t work, he would do it a different way. 

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BMJ Writer Discovers Head Up Ass

photo of a kid on the beach with a clenched fist and the caption "I hate sandcastles."

John C. McLachlan is a professor of medical education who wrote an article in the British Medical Journal (BMJ 2010; 341:c6979) called “Integrative medicine and the point of credulity.”  McLachlan proposed that integrative medicine should not be used as a way of smuggling alternative practices into rational medicine by way of lowered standards of critical thinking. He worries that failure to detect an obvious hoax is not an encouraging sign.

The author, upon seeing a request for presenters at an integrative medicine conference in Jerusalem, submits a paper posing as an embryologist who discovered a new version of reflexology. He explains that he has identified a homunculus represented in the human body, over the area of the buttocks. The homunculus being inverted, such that the head is represented in the inferior position.  As with reflexology, the “map” responds to needling, as in acupuncture, and to gentle suction, such as cupping.

He stops short of telling the conference organizers he has discovered a system whereby the head is up the ass and responds to needles.  Funny, right?  Well, after submission of an abstract with some sciency sounding references, the proposal gets accepted for presentation.  The author declines to present and, instead, publishes the correspondence in the BMJ.

Now, I’m all for having a good laugh at the expense of wacko alternative medicine practices but my goal is clear — I want to help clean up the field in order to highlight the people who are actually doing some good, honest, logical research.  I actually have a problem with what Dr. McLachlan has done.  By poking fun from a distance and walking away without letting the conference organizers in on the joke, the author misses a huge opportunity to educate and possibly improve that which he criticizes. It would have been far better if he accepted a slot at the conference and awaited to see if people would point out the errors in his “research” or simply used the platform to show what bad science is.

The only thing that makes him not a 100 percent coward is that he published his story. Someone who asks difficult questions so that when you answer incorrectly you will learn is called a teacher.   To ask difficult questions and then tell your friends how stupid someone is without letting them in on where their error was is called by a different name entirely.

Remember Smith’s article about how parachutes aren’t evidence based? That one is funny and brilliantly illustrates its point. This article, while funny with its head-up-ones-ass ha ha I get it humor, is really only about as funny as watching your kids get their math homework wrong and, instead of helping them, you call all of your friends and laugh at your kids’ ignorance. Nothing was learned. Nothing was improved and we all feel a little bit sick for participating in the joke.

Yes, it was a hoax but science relies on some degree of honesty and trust.  It is impossible for one scientist to be at the apex of all fields and know all that is known from every discipline.  Isn’t that why we have specialists?  Could it be that the scientific committee accepted McLachlan’s proposal simply in order to learn whether or not this revolutionary discovery was plausible or bunk?  Unlikely, but possible.  Today, I would rather lend the benefit of the doubt to the conference organizers rather than the scientific playground bully.

 

Brett L. Kinsler is a chiropractor in Rochester, NY who writes the RochesterChiro blog and produces the podcast On The Other Hand.

 

Podcast Episode: What Do Athletic Trainers and Physical Therapists Think About Chiropractors?

 

Timothy Mirtz, DC PhD from the University of South Dakota chatted with me about what athletic trainers and physical therapists think about chiropractors and what can be done to change the interprofessional relationships.

Find it on iTunes by searching for OnTheOtherHand or go here.

This is our first episode with our new sponsor. It’s very cool that a great business sees the value in our podcasts and wants to help us continue to make them.  I would appreciate if you would check out coldlasertherapy.us I’ve used them for years to buy all of my cold laser equipment. They have really fair prices and excellent customer service.  Complete cold laser setup with two pairs of safety goggles for under $1600.  For real!  Plus, listeners to the podcast get $50 off their order by using coupon code: PODCAST

Our Podcast is Coming!

I just wanted to let you know that the podcast episodes are coming along nicely.  Today, I posted an introductory episode to make sure everything is working properly. It should be available in iTunes very soon.

The series is called On The Other Hand and it will contain interviews, commentaries and rants with responsible, scientific people in chiropractic, alternative medicine and healthcare.  Most of the interviews will stem from West Hartford Group members (the chiropractic think tank) but there are others as well from within and in other professions.

I’m just getting started so there will be a learning curve; I will have to play with the audio settings until it all sounds right, but hopefully it is something you will enjoy.

Episodes can be found at iTunes soon but will also be posted, along with show notes and links, at:  http://ontheotherhand.podbean.com/

So far, only the test episode is there but I do have complete episodes on their way!  Let me know what you think and please vote for me on iTunes to ensure rational, scientific information predominates when someone searches for “chiropractic podcasts.”

Dr. Brett L. Kinsler is a fulltime chiropractor, a sometime blogger and a first time podcaster.

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Bad Advice

Not so long ago, my office manager asked me to take a phone call.  Someone was asking if we do a certain technique. This was not an uncommon scenario — people call all the time wanting to know if we can do what their doctor in Peoria did.  Many times we can, sometimes we don’t but it never hurts to ask.

This particular person was asking about a chiropractic technique my assistant had not heard of so she punted it to me. My feeling, and the research generally agrees, that most chiropractic techniques get you to the same place.  The old-timers used to say it didn’t matter if you took a bus, car or train — they all get you to about the same place eventually. So, whether someone adjusts your spine with the push of a hand or the thump of an instrument, whether the table moves with the adjustment or lights up like a winning slot machine, most chiropractic techniques can eventually help patients in pain.

However…the techique this person was asking about is, well, bull. Plain and simple. If you saw it done, you would laugh your ass off.  Seriously. Right off. Gone. It’s disproven, silly and so far from the realm of scientific reality it would make Stephen Barrett squeal like a little girl. Of course I took the call.

“Hello Ma’am. Yes, I heard that’s what you were looking for. Oh, I’ve heard of it alright. Oh boy. Well, you do know there is absolutely no scientific evidence supporting that technique, right? No, none. It’s garbage. Huh? Right, so you know it’s a complete waste of your time and money? Okay, well I certainly don’t use that procedure in my office and I really don’t respect anyone who does. I couldn’t possibly. Why?!? Because they are basically criminals; lying to patients and tricking them with pseudoscientific jargon and useless tests that are light years beyond ridiculous.  In fact, anyone who uses that technique would have to be the worst chiropractor in town. What’s that now? Really? You’re kidding me?”

“Ma’am, are you actually asking me to refer you to the crappiest, most dishonest, clinically incompetent doctor I know? Please hold for the number…”

And so it went. Clearly there was a huge disconnect between what this woman wanted to hear and what she needed to hear. I thought I was doing her a favor by smoking her beeline to quackville. Instead, she just wanted the information she wanted in the way she wanted it.

I have a friend who told me he stopped going to his primary care physician since she always gives the same advice.  He once went in for an ankle sprain and he swears she told him to diet and exercise.  He’s the same wiseguy who when she questioned how he was working on his type 2 diabetes, he responded “Positive thinking?”  The problem is that patients frequently don’t want to heed lifestyle changing advice even if that’s what they need to hear the most.

Recently, I was asked for advice on how someone could lower her cholesterol without medications. I told her to try a low-fat, whole foods, plant-based diet. She tried it — for one meal. Then she gave up, citing it as too difficult, and reverted right back to what she was already doing. Six months later she had her blood retested. Shocked! Shocked! that her cholesterol was even higher that it had previously been!  I was again asked for advice on how to lower this skyrocketing cholesterol.

“I am not going to answer this question since you already know my advice,” I said. “If you want some new advice, you really should be asking someone else.”
“Oh, not the vegan thing again,” she sighed, “I was hoping you would tell me something different.”
“Yeah,” I said, “but that is the absolute best advice I have for you. I can give you bad advice. Is that basically what you’d like? Some bad advice? Okay. You should be performing the Mexican Hat Dance during all lunar eclipses in months with a R in their names. That will shoot down those triglycerides like a cartoon anvil falling out of a helicopter. And while you’re at it, smear peanut butter between your toes every night before bed. That will ward off the evil aliens from the planet Cholesterak that inject cholesterol into your blood while you are sleeping.”

I can be chock full o’ bad advice.  Piece of cake. But it’s a metaphor, isn’t it? It’s always a freaking metaphor. I’m chock full of those too.  We know the answers to so many questions in our lives but choose to look the other way. Often, we have the solutions to our health problems but we simply do not want to hear the answers that will actually help. 

How about you? Are you just looking for the advice you want and ignoring what you need?

Is there something you haven’t heard lately?

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Yes Is The New No

There is a truth in science.  There is a right and a wrong answer even though we may not always find either one.  Science is not a belief system and scientists try to reject assumptions that cannot be tested in favor of facts.  It’s nothing personal.  There is just a difference in pedigree between science and faith.  Which is not to say I do not hold beliefs that I have not tested.  I do. 

For example, I believe you can catch more flies with honey than vinegar though I have never tried.  I also believe I don’t want to catch any flies. I also believe I don’t believe I want those little buzzy SOB’s barnstorming my ears.  But, having the vegan tendencies as I do, I believe I don’t want to kill the little buzzy SOB’s either.  Maybe vinegar is a better choice.  I don’t know.  At least I can feel like I am doing something without harming living things.

There was a point to this somewhere. Oh, yeah.  Negative attitudes. I’ve caught some flack lately for being a tad bit negative.  Moi? No! Okay, just a titch I suppose.  I admit I don’t usually play Susie Sunshine in the grade school play when I see the stupidity on the morning lineup that can be my profession — or healthcare in general for that matter.  I call it like I see it. I think that’s part of my job.  Calling it loud and obnoxiously is just a value-added service I offer.  As my wife likes to inform me, I might, occasionally, once in a while have a hard time not saying the exact thought that pops into my mind.  She says this like it’s a bad thing.

Like the other day in a restaurant.  The waiter asked my friend, “You wanna box for that?” indicating his three leftover tortellinis.  I said, “Really? You’re going to kick his ass over a couple of tortellinis? Dude, if you want them that badly, you should just take them.”

Maybe that’s what my wife means.  Anyway, I am told this negative attitude could be bad for the profession.  I get it.  I need to have a more positive outlook and focus on the positive stuff. I need to waive the cheerleader pom-poms and rah-rah the pants off the chiropractic profession! Go00000 team!

I’d like to.  I really would. There is a lot to be positive about. At least things are moving in that direction. I need to see more greatness but there is some really good stuff going on.  I am just not sure I am the right guy to applaud mediocrity and fake cheerfulness.  I don’t think that’s what I signed on for.  Last I checked, the door I walked through said “Truth”.  At least that’s what I thought it said.   Maybe it just said “Push”.  I saw it as the same thing.

 

Dr. Brett L. Kinsler is a chiropractor in Rochester, NY who is working on his negative attitude problem.

Missing the Call

I’ve had some pretty interesting jobs.  I used to set up balloon displays for weddings and bar mitzvahs.  I worked in organ and tissue recovery removing human parts for transplant.  I even worked, for short stints, on an ice cream truck, in a bank, in an amusement park and in late night food delivery.   From every job I learned something — some skill or lesson that I continue to use in my practice. 

This week, a patient told me he had gone for an MRI for a problem that I was not treating him for (a possible cartilage tear in his shoulder).  He was very upset that he did not have an appointment with his orthopedist for another 4 weeks.  An entire month of wondering if he would need surgery.  He wanted to plan a vacation but was hesitant to do so if he would need to save up his time off from work.  His family history of cancer was also worrying him; he wondered if the MRI had illuminated bone cancer as the cause of his shoulder pain.  He was worried, anxious and not sleeping well.

One of the jobs I had prior to chiropractic school was performing clinical testing for a medical device that measured early signs of breast cancer without ionizing radiation. (It looked kind of like an EKG for the breast and measured surface electrical potential which is different in cancer cells vs. normal cells).  This job required me to spend time in several mammography clinics around the world.

One of the things that stuck with me from this job was the way one particular radiologist ran her clinic.  It wasn’t sterile looking with tile floors and paper gowns.  Patients were treated with dignity.  Real pillows and sheets on the exam tables.  Carpeted rooms.  Women were given a mammogram and then went into a comfortable waiting area where they could have a cup of tea and wait.  The mammogram was read by the radiologist while the patient was still in the building and she would be given the results right then and there….that very day.  I had heard horror stories of women with breast lumps going for mammograms and not getting the results of their test for weeks.  That can make for a very long, sleepless time period.

I hear this too often.  Patients are sent home to wait.  No news is good news, right?  Wrong.  We should be actively giving patients their test results as quickly as possible.  Sure, we know it’s just a standard blood workup or x-ray or CT, but to the patient, we’re going to spot the same thing that wiped out their uncle Frank in his 40’s.  Every patient who has an x-ray has the same thought, if only for a second:  I have cancer or something horrible and this is the test that’s going to show it.  Some of them are correct but they have the right to know.   Be proactive to get test results quickly and call your patients with them.  Don’t even wait until the next appointment.  (And for Heaven sake, don’t call them and tell them you see something and they need to come in to discuss it in 2 weeks).   They’ll be back in to see you regardless and the goodwill you generate will outweigh any lost office visit fee.

Oh, what about my patient? I got those MRI results for him before he even hit the door to leave my office.  Negative for cartilage tear.  Just some inflammation.  Looks like that trip to Cabo is on!

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Dr. Brett L. Kinsler is a chiropractor practicing in Rochester, NY

Deformed Consent: It Was a Million to One Shot, Doc!

Informed consent in healthcare is the process by which the provider informs the patient about the options for the diagnosis and treatment of the patient’s condition. In addition, the risks and benefits are described to the patient so that the patient can make a rational decision regarding what he or she wants to be done.

Informed consent is a good aspect of healthcare. Giving patients the information to make decisions about their health preserves their right to autonomy. Many people mistakenly believe that informed consent is simply getting a patient to sign a written form. It is more than that. It is a process of communication between the patient and provider that results in the patient’s authorization or agreement to undergo a specific intervention. Patients should always have the opportunity to ask questions to elicit a better understanding of treatments or procedures. Patients should always be able to make an informed decision to proceed or to refuse a particular intervention. All medical encounters should conclude with the patient agreeing that all his questions have been exhausted. And patients should be adequately advised patients prior to any procedure in order to exercise the patient’s right to choose which side of the risk/benefit table he would like to place his chips.

So how do we fully inform a patient? In order to be as fully informed as his doctor, must the patient be sent to medical school? Actually, yes. By committing even minor omissions, doctors fail to deliver a fully informed consent. After all, patients who do not have the same medical knowledge as their provider can never truly comprehend all of the risks of a given intervention in the same way their doctor does. And what of minor, but likely possibilities? Should we be required to tell a patient that he may get a papercut by handling an informed consent form? What if the patient refuses treatment, and in his haste to exit, gets a static electricity shock from the doorknob. No big deal, right? Not worth metioning, right? What if that shock shorted out his pacemaker? Ahh…bigger deal. Should we have provided the warning to this possible, but foreseeable event? Can you picture the huge disclaimer poster required to be put in medical waiting rooms informing potential patients of all risks and benefits of opening the door to the office hallway? And another poster in the hallway denoting all of the risks of entering the treatment room. I don’t even want to imagine the one in the restroom.

We would most certainly have to stop offering coffee and tea in the waiting area. I mean, right now, the cups come pre-printed with: CAUTION – CONTENTS MAY BE HOT. I am not sure there would be room on the cup for: CAUTION – CONTENTS MAY BE HOT, WET, CAFFEINATED, DECAFFEINATED or SWEETENED. MAY STING EYES, CAUSE DIABETES, CANCER, ANXIETY, HYPERTENSION or DROWNING. DO NOT INVERT OVER EYES, EARS OR PRIVATE PARTS. DO NOT INSERT RECTALLY. WARNING IS CONTINUED ON NEXT CUP. NO, NOT THAT ONE, THE BROWN ONE. And of course all written warnings need to be in 6800 languages in case someone who understands only Luxembourgish wants a cup of joe.

Informed consent is an excellent idea and one that healthcare should embrace…within reason. Patients have a right to the explanation of procedural or invasive risks in advance. Exclusive of emergency procedures in life threatening situations, informed consent should be made available whenever possible for significant risks with a high estimated likelihood of occurrence and tempered with the potential benefits and alternatives. Minor risks would take too long to explain, and would cloud even the most simple of procedures: “I’m going to draw blood from you now, Mrs. Smith. By inserting this needle in your arm, I am exposing you to the following 40,000 infinitesimally small risks which I shall explain in detail one at a time….” The delivery of informed consent would take hundreds of times longer than any actual procedure!

As for chiropractic, there are, of course, some common risks. These risks are usually temporary and minor, involving things like post treatment soreness. There are also a few major risks which, in terms of likelihood of occurrence, are more akin to choking on an aspirin tablet. To date, there is no warning on bottles of Bayer aspirin telling the user he may choke and die on the tablet. It certainly is a real risk with such a low likelihood of occurrence, it hardly warrants mentioning. If a patient asks if there is a chance of dying by choking on an aspirin, his doctor should address the concerns honestly and directly. I am not implying that doctors should skirt around any patient questions but a proactive stance for remote risks does neither the patient, the doctor, nor the entire field of healthcare any good.

In communicating with our patients, we should make sure they understand that which is likely and that which is serious. The operative action here is to communicate. If we strive to improve the doctor/patient relationship, and provide honest, open communication, we would do much to reduce the reasons informed consent has exploded into ridiculousness in the first place.

Brett Kinsler is an informed and consenting chiropractor in Rochester. NY

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Could Your PCP Pick You Out Of A Line Up?

DocBaker

I doubt mine could.  Which makes me think about Little House on the Prairie.  Anyone around in the 1970s remembers idyllic Walnut Grove, where Doc Baker took care of everyone and their pets.  He gave advice, dispensed medicines and sent the tough cases to Mancato (the big city).  People ran into him at the general store and he promised to stop on by the next time he was out their way.  To our modern ears, it sounds very quaint until you realize that this is the model of health care that we aspire to and were supposed to get with the onset of HMOs.  Under that model, we were each supposed to have a PCP who would monitor our health, give us lifestyle advice and send us to a specialist if any red flags showed up.  This would be the ‘gatekeeper’ (insurance term) that would be familiar enough with our health history that his or her decision would be one based on a long view of our individual health status.  Unfortunately, this model was managed to death by efficiency experts until it is neither efficient or effective.  The political choices we have before us continue this trend. Until we as patients demand better, the push will be for PCPs to do more with less.  In a recent poll (Investors Daily)  45 % of primary care physicians will consider quitting medicine if the government takes over the health care system.  That is approximately 360,000 doctors that will consider quitting practice.  Clearly, doctors are as frustrated as their patients.  Health care reform, to make any meaningful changes needs to redefine the role of doctor and patient.  The most efficient role the doctor can play is health coach in a proactive way.  That can’t be done in 5-10 minutes once a year. Or with a quick blood test.  Patients that are empowered by their relationship with their doctor will make the most beneficial (and coincidentally, the most cost-effective) changes to their own health.  In that climate, there will be less of a role for bean counters and government pencil pushers.  Let’s not give up the idea of Doc Baker too quickly. 

Dr. Michalene Elliott is a chiropractor in Rochester, NY who doesn’t want to be managed anymore.

What’d Ya Say? Divided By a Common Language.

applesoranges

The importance of using common language when communicating about back pain has been well documented in the medical literature. There are three main areas that lead to difficulties in communication about back pain:

  • patients seeking information from health care professionals can experience difficulties understanding them and the medical literature
  • misunderstandings among health professionals concerning terminology can arise
  • lack of standardized definitions for back pain terms can make comparison of research studies problematic

A study just published in the BMC Musculoskeletal Disorders aimed to explore the meanings and issues surrounding the use of existing medical terms for back pain from the perspective of health care professionals and lay people. Focus groups were used to explore participants’ understanding and samples included general practitioners, chiropractors, osteopaths, physiotherapists, and lay people.

Lay participants understood the majority of the terms explored in the group differently than the health professionals. Some terms were not understood, some misconstrued and some had inadvertent negative connotations or implications. (For example “wear and tear” instead of the harsher term “degeneration” gave implications of wearing away or rotting).   The commonness of misunderstandings, unintended meanings and negative emotional responses to terms used in this study have a number of implications.

Firstly, it must encourage providers to ensure their patients understand what has been explained to them including the contextual and emotional implications. Secondly, patients and providers should have an ongoing dialogue to promote understanding of terms and comminality of language.  Third, this study should be used as a lesson to chiropractors who cling to old, antiquated terminology that we know has differing meanings both intra- and interprofessionally. If other chiropractors cannot agree on a term’s meaning, and other professions cannot agree on that term’s meaning, you can sure as heck bet that your patients have no idea what you are taking about either.

I was recently told that we should take antiquated terms and reframe them so we can continue using them in a different context. To me, this study implies that is not a wise course of action.

 

Brett L. Kinsler, DC is a chiropractor in Rochester, NY who avoids using antiquated terms when he blogs at www.RochesterChiro.wordpress.com

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