Spinal Screaming

Scene: Shopping Mall.

Wedged in between the Yogan Frooz (motto: made up Scandinavian words tastën groövi) and the Cell-U-Cessories cart (motto: I’m a bored guy on a stool) one can occasionally spot what is commonly called a chiropractor performing what is commonly called a “spinal screening”. Step right up and you can get your spine checked for problems. No back pain? No problem! These little spine problems are sneaky buggers and have a funny little way of creeping up and kicking your ass. You may not even know you’ve got one until it’s too late. Like appendices that always seem to be removed seconds before they were going to burst (whew, thank God! The size of a grapefruit you say?) these spinal boo-boos can wipe you out! What’s that, Miss? You just had a checkup at your medical doctor’s? Last week? And he didn’t find any spinal problems? Didn’t he? Well, that’s okay – you’ve got to be a chiropractor in order to finds ‘em and fixes ‘em. Here’s my card. We’ll see you at 9:00 am tomorrow. NEXT vict- I mean screening subject!

You might be asked to stand on two modified bathroom scales, one foot on each. Notice how the weight isn’t the same on the two scales? AH HA! Structural imbalance! Or, you might stand against a metal frame with strings going across it and the chiropractor will slide the strings to match up with your shoulders and hips. You step down and AH HA! Those strings aren’t level! Spinal problems! Or perhaps Dr. RightbySears is taking the high tech approach and running a scanning device up and down your spine and them shows you on the computer screen what looks like a bar graph coming out of both sides of your back. Some areas are blue, some yellow and uh oh, you’ve got red ones! You need to come in to my office Monday morning and turn those red things into blue.

Public screenings are an important tool in improving the public health. True, screenings for prostate and breast cancer have taken some hits in the literature but the practices are changing in alignment with the scientific evidence (slowly, but responding). The spinal screenings you see in the mall are not the same as having your blood pressure checked by the volunteer ambulance outside the Stop & Shop. Elevated blood pressure has a clinical correlation with chronic disease and the blood pressure cuff is a proven method of detecting hypertension. The evidence for using two bathroom scales for determining the need for future spine care? Clearly demonstrated in the American Journal of Notsomuch. That fancy scanning thing that produces the sideways colorful bar graphs? Just saw it in last month’s New England Journal of Maybenot. Unproven to be anything other than a marketing gimmicks.

Screening is a public health activity with the aim of detecting disease before symptoms appear. Screening has the potential to save lives and improve quality of life through early diagnosis of serious conditions but can only be ethically used in cases where the screening procedure can actually detect what it proposes to find and the early detection will actually make a difference in the progress of the disease. For example, more than half of seniors have hypertension. One could be accurate half the time waving a magic wand over a group of people over 65 and declaring a diagnosis of high blood pressure in half of them. Accurate? Yes. Ethical? Hardly.

To call these advertising booths ‘screenings’ is a slap in the face to true public health measures. Screenings should identify or prevent a public health concern – not create patients through scare tactics, confusion and deceit.

I have no problem with people marketing their businesses as long as they call it what it is. When I see an ad in the newspaper for a cafe that says it has the world’s best coffee, I’m pretty sure there wasn’t a scientific poll organized to determine it. But it’s different when a doctor does it. It needs to be different.

Setting up a booth in a mall looking for people who will believe what you are selling is not a screening for public service. It’s a store.  And if you sell items or services by lying, then not only is it not a screening but it’s a self-serving  fleecing. These people should have telemarketers for older brothers so they’d have role models to look up to. Run away. All the way to the Gap if you have to.

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Who’s Responsible?

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I am fortunate to have known, worked with and met many successful and intelligent chiropractors during my years as a student and in practice. Some have been my own chiropractors, my practice partners, fellow board members, local go-to resources, mentors and profession leaders. Some of them stand out as doctors worthy of entrusting the referral of any family member without reservation; those who are held in the highest esteem; those who show chiropractic in its best, most positive light. For these doctors, the term “responsible chiropractor” partially describes the model of practice they embrace. Most of the time, this term is plainly understood. For example, telling a colleague you are looking for a responsible chiropractor in the Los Angeles area will usually lead to the desired recommendation. The problem is that “responsible chiropractic” lacks a solid definition and the circumstances and practice styles of these doctors seems as varied as any group of chiropractors can be. Or is it? Upon reflection, it is obvious that there are some commonalities among responsible chiropractors and I have set out to answer the question, “What makes someone a responsible chiropractor?”

The dictionaries were of minimal help. They brimmed with definitions of responsible like “able to answer for one’s conduct and obligations” and “trustworthy”. Eh. Not specific enough. The concept of responsible chiropractic like that phrase turned by US Supreme Court Justice Potter Stewart in the 1960’s when he attempted to define a threshold of obscenity: “I know it when I see it.” Responsible chiropractic is nearly as difficult to define but I’m sure I know it when I see it. Good enough? Hardly. I am not willing to leave this definition up to an entirely subjective Stewartian standard. To do so would be far too intangible for a manual provider like myself. Therefore, we must first define this obscure concept and attempt to determine, with apologies to Stephen Covey, what in fact are the habits shared by these highly responsible chiropractors.

Let’s begin with what responsible chiropractic is not. Lest you think otherwise, it is not simply practicing the way I do, dressing the way I do, thinking the way I do, etc. I have no desire to see the entire chiropractic universe a clone of this Rochester chiropractor though I’d like to think I fit into the definition. Responsible chiropractic is also not simply being science oriented and evidence based, although both surely are a strong facet of the big picture. And it is not about being ethical — though show me a chiropractor who is responsible and I’ll show you one who is ethical. Responsible chiropractic is neither driven by a specific technique or school or organization or state or shape, size or color. So what attributes are shared by the responsible chiropractors I’ve known?

First, responsible chiropractors do not readily embrace concepts that will not pass the sniff test. The application of this informal reality check to an idea, product or new technique combined with a healthy dose of common sense leads responsible doctors to determine when something about an idea smells foul. And if it can’t pass the sniff test, responsible chiropractors throw it away. You won’t find disproved techniques or questionable diagnostic devices in their offices unless they are hidden in the closet collecting dust. Untested and off label procedures, if applied, are slathered first with a thick layer of skepticism and explained to patients.

Both the fees and treatment plans of responsible chiropractors are reasonable. The doctors make a comfortable profit in their offices but do not take advantage of their patients financially or temporally. Their treatment plans are based on clinically reasonable guidelines or at the very least are not based on a treat ’em till their spine falls out protocol. The patient’s best interest is at the center of nearly every clinical and business decision. Prepaid treatment plans are not part of their standard practice. The use of radiological procedures in the absence of red flags is avoided by responsible chiropractors as is the use of x-rays as a marketing device. A lifelong reliance on passive care is avoided by responsible chiropractors and moving patients to active, self-care is encouraged in general.

When explaining procedures and diagnoses to their patients, responsible chiropractors use accurate, scientific descriptions, simplified perhaps, rather than using the opportunity as an excuse to confer unscientific, antiquated concepts simply to make it easier to ‘sell’ a patient on a treatment plan. Responsible chiropractors don’t actually sell patients on anything — they educate, inform and provide the patient with options, assisting the patient in making health care decisions rather than scaring the patient into treatment. Any marketing done by responsible chiropractors is devoid of hyperbole, exaggeration, half truths and blatant lies. Marketing that might embarrass the profession is abstained from entirely. And they eschew poisoning the public well, the practice involving aggressively selling to large groups of people with the hope that 1 or 2 out of every hundred will become patients while the other 98 or 99 will never consider chiropractic as a result.

The disparaging of other practitioners, both within and outside of the profession is avoided by most responsible chiropractors. This does not mean that dangerous or unethical behavior is ignored. Responsible chiropractors, upon witnessing irresponsible behavior from colleagues, will attempt to protect the profession of chiropractic and the public by informing the offending practitioner or the appropriate authorities.

Living in a protective bubble is not acceptable to the responsible chiropractor nor will they allow themselves to exist on an unsocial island devoid of other professional contacts. They communicate with and learn from colleagues both in chiropractic and in other professions. They seek opportunities to meet with others in person, by telephone and via electronic means in order to learn and exchange ideas. When possible, responsible chiropractors embrace interdisciplinary practices, events and educational opportunities. Referring out of patients to other practitioners if the patients are not responsive or are not good candidates for chiropractic is done readily and without delay. Responsible chiropractors have a list of people they trust to take care of their patients if the patients need something they cannot provide or the patients have failed to improve rapidly.

Continuous, lifelong learning is central for successful responsible chiropractors. This includes learning how to honestly build and maintain their practices so they can stay in practice and continue to help patients. More learning time, however, is spent determining what is new in the field, what works and what doesn’t. And the material that is read always includes high quality journals since responsible chiropractors can tell the difference between good research and poor. In short, responsible chiropractors strive to become the most effective clinicians or educators they can be…and then attempt to surpass that level.

There is a great deal of leeway in defining a responsible chiropractor and thankfully there are many to emulate. I do feel the paradigm shifting in our profession and it is getting easier to find the people who are practicing responsibly. I do not mean this article as an attack or a diatribe on what is a good or what is a bad chiropractor but rather it is an exercise in the identification and illumination of the beneficial portrayal of our profession by a collection of doctors with whom I am acquainted and with whom I am proud to be associated.

Live & Let Live or Sort ’em Out?

carefulSome of my more outspoken opinions (who, moi?) on topics like decompression and autism have sparked an interesting debate that is being held mostly by private email.  Without naming names and pointing fingers, I would like to hear what you think…

If a colleague is practicing in a manner that you find objectionable and unethical, what should be your course of action, if any?  Some people are saying that people should be able to practice however they see fit and writing like mine actually harms the practices of others.

Other folks say that it is the job of honest, ethical chiropractors to weed out the “sick” members of the chiropractic flock in order to advance the heard.

Yet another sect says that, yes, in fact we should denounce unethical practices but for Pete’s sake, do it quietly.

Ready for a fun social experiment?  Here is a practical, real world example and I will abide by the most convincing argument.  I was recently given an advertisement of a chiropractor who is basically offering money for referrals of patients.  Illegal?  Probably.  Unethical?  Definitely.  Should be stopped for the benefit of the profession?  Certainly.

What to do, what to do.careometer

Choice A: Ignore it and let him go on doing what ever he wants — after all, he’s a fellow chiropractor.

Choice B: Send Dr. Bribes-a-lot a private note asking him to kindly stop making the profession look bad.

Choice C: Pass the ad along to the state board and let them handle it.

What do you think?

More Spinal Decompression Lies You Should Know

None of my blog articles have caught more attention or been the subject of more flack than when I tell the truth about non-surgical spinal decompression like the VAX-D, DRX-9000 and other pieces of equipment that are similar.  You will recall that I am not against the use of these machines in general — only that the marketing of them is seriously misleading and the practitioners who use them frequently sell patients on long term, prepaid care plans that are highly unethical.  The marketing of non-surgical spinal decompression also frequently falsely claims superiority over other techniques like flexion-distraction — such claims have not been proved.

As a result of some of the feedback I have received, I came across an article from the journal Chiropractic & Osteopathy titled “Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?” published in May 2007.

What’s the bottom line?  Does the decompression hype live up to the claims?  That’s a big, giant, whopping “NOPE!”

A little more detail, you say?  Okay.  The article examines this “heavily marketed” version of traction therapy that “can cost over $100,000.”  The authors extensively search all the major medical and scientific literature databases to find every scientific research article published on nonsurgical spinal decompression.  It turns out,  there was only 1 randomized controlled trial, 1 clinical trial, 1 case series and 7 other papers.  Each was reviewed individually. 

The authors concluded that “In general the quality of these studies is questionable.”  And that there was “only limited evidence…available to warrant the routine use of non-surgical spinal decompression, particularly when many other well investigated, less expensive alternatives are available.”

Gee, that sounds just like what I told you a few months ago.

 Also interesting was that this intervention has never been compared to exercise, spinal manipulation, standard medical care or other less expensive conservative treatment options which have an ample body of research demonstrating efficacy.  How the practitioners can get away with claiming any superiority and not be restrained from doing so is a mystery to me.

I’m not saying that any chiropractor who has a spinal decompression unit is a crook.  If he or she is charging you the same as a regular visit in order to use the experimental equipment, then that may be fine.  If he or she tries to convince you to pay in advance, sign up for a dozen or two visits or tells you how fantastic the device is compared to other treatments, don’t walk….run away and find another chiropractor.

Speaking Engagements

This has been a great year for me with respect to speaking engagements.  I was invited to speak at the American Board of Trial Attorneys’ continuing education program where I taught a section on spinal anatomy for attorneys.  Then, I was invited by the University of Rochester Office of Prehospital Care to teach in their lecture series at fire departments and ambulance corps in two counties.  I completed teaching the ‘Protect Your Back for EMS Workers’ lecture and have just started teaching ‘Ethical Decisions in Prehospital Care’.  The feedback I have been getting is excellent.  It seems that people really appreciate continuing education lectures that are well-prepared and engaging and I am happy to oblige.  I don’t think I would like teaching something I didn’t find interesting.

I have certainly learned a great deal of respect for all of my prior teachers and university professors as the time it takes to prepare a really good one or two hour lecture is at least 10 fold greater!  Luckily, these lectures are being repeated in various agencies so at least I can recycle the time spent in preparing them.

 

Dr. Brett Kinsler, chiropractor in Rochester, NY, is available for speaking engagements on a variety of topics in healthcare and emergency medicine.  He can be reached through his website at http://www.RochesterChiro.com

Doctor-Patient Relationship

As in all branches of healthcare, the doctor-patient relationship is paramount to the practice of chiropractic, but is an extremely complex interpersonal exchange.  The relationship must be strong and be based on good communication, openness and trust in order to facilitate a proper diagnosis and treatment.  The patient must trust his chiropractor and have confidence in his training, competence and continuity.  The chiropractor should be adept at making patients feel at ease and developing rapport.  A sense of humor is important for making a patient feel comfortable and reducing tension.

 

The doctor-patient relationship is the cornerstone of medical ethics and goes well beyond the legal covenant of patient privilege.  The doctor of chiropractic has numerous duties to the patient in their partnership, including:

 

  • Beneficence – assisting the patient in improving his or her health and conditions
  • Non-malfeasance – first, do no harm
  • Respect for patient autonomy, choice and individuality
  • Respect for patient dignity, privacy and right to confidentiality
  • The doctor’s role is to guide the patient in making treatment decisions in the patient’s best interest.

 

The chiropractor should be available to patients in an emergency situation, willing to return phone calls to answer reasonable questions and prompt in reporting test results to patients.

 

Patients can assist in the doctor-patient relationship by:

 

  • Being prepared with their questions and concerns in advance of a visit
  • Respecting the doctor’s time and professional boundaries
  • Ensuring their chiropractor has an up-to-date listing of their medications, surgeries, allergies and health conditions
  • Ensuring third-party payer arrangements and financial obligations are met
  • Having realistic expectations in their goals
  • Be willing to be an active participant in his or her treatment plan

 A good Patient Provider Interaction Resource can be found here.

Non-Surgical Spinal Decompression – Fact or Crap?

Yesterday, a patient came to my office and told me her medical doctor sent her to me to see if I did spinal decompression.  For those of you who don’t know, non-surgical spinal decompression uses a specialized type of chiropractic table that provides computer assisted traction in order to separate the spinal bones and promote disc and ligament healing.  Devices are known as the DRX-9000, VAXD, Lordex, DRS and others.  The problem is, there are too many problems.

  • Spinal decompression is a good procedure but has not been shown to be any better than techniques like Flexion-Distraction.
  • Providers of spinal decompression almost always claim superiority of their technique over others.
  • Spinal decompression devices are much, much, much more expensive than traditional flexion-distraction devices.
  • In order to pay for their expensive, computerized tables, many spinal decompression doctors resort to false or misleading advertising, pre-paid treatment plans and other unethical practices.
  • Decompression chiropractors frequently prescribe a 20 visit minimum treatment protocol (usually at about $200 per visit!!) for which there is no clinical rationale.  Many of these patients would get better faster with other treatment methods.

I don’t have a problem with the DRX-9000 or other SD tables in and of themselves.  The theory is pretty good and mirrors the excellent results we obtain with flexion-distraction for disc herniations and bulges.  I have a major issue with the false and misleading practices, the high-pressure sales tactics, the false claims of superiority and the pre-paid treatment plans.  I also don’t feel like paying an extra $60k to hook my table up to a computer. 

I sent the MD who inquired about the technique a nice letter along with a copy of some of the articles naming lawsuits concerning the spinal decompression practices and some of the major insurance company positions on decompression (is it considered experimental and no better than currently available procedures).  It would be nice to see this become a legitimate piece of equipment as a tool for chiropractors to use but as of now, there is too much controversy and too many unethical practices associated with it.

Dr. Brett Kinsler is a chiropractor in Rochester, NY.  He gets excellent results with patients who have disc injuries in his Rochester chiropractic office and does not need to resort to hype and lies. His website is http://www.RochesterChiro.com

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