Let's Take a Few Steps Back and Maybe Change Our Approach
By Louis Sportelli, DCAs most of you know, these columns are prepared a month in advance, which makes it difficult to be as current as we would like to be. However, the month of December certainly came in like a lion and appeared to also exit like a lion.
One of the major negatives was the series of articles that appeared on the Canadian Internet Network (CANOE) on Sunday, December 12, 1999. Under the title "Spin Doctors: Deaths, Deceptions and Dubious Claims Haunt Chiropractors' Bid for Academic Acceptance," CANOE launched a very impressive "investigative" report that was especially written and developed for the internet. (Go to www.canoe.ca/ChiroYork .) The creativity of the internet story was, without a doubt, superb. The interactive matrix incorporated into the design was intriguing, incorporating audio snippets, interactive polling and hyperlinks to many other sites. For creativity, CANOE and the reporters get an A+.
However, it soon became obvious that the investigative journalists were engaging in yellow journalism. We've seen "hatchet jobs" on the profession in newspapers and on television; now we're treated to the era of "virtual internet condemnation." The reporters did their homework and gathered as much negative information as they could find, designed to accomplish an end objective. The coup de grace was the hyperlink to the ramblings of Stephen Barrett at his Quackwatch website.
Some chiropractors were aware of the CANOE site and participated that Sunday, but most of the profession was oblivious to the systematic dissection of the profession. Those who did could only grab a mouse and click and point, as if this deception designed as a video game would soon be over and an honest, dispassionate program about chiropractic would begin. Unfortunately, this was not an illusion. Because of the technology used, it will take on a life of its own.
Let's look at the information presented on the site, and see if we can objectively, dispassionately, and professionally make some sense of it, or at least attempt to learn what we must do to counter these kinds of attacks. The reporters asked that you "draw your own conclusions about the organizations and information" presented on the site, as if this small disclaimer would make everything right or demonstrate objectivity.
The reporters began with the CMCC's proposed merger with York University. They made sweeping statements about deception by CMCC officials to York officials and deemed their pronouncement to be the truth. Then, in a quantum leap of journalistic faith, the reporters jumped to a Canadian neurologist who pronounced that as many as 150 strokes a year result from chiropractic neck manipulation. His statement was treated as gospel, although he had no substantiation for it. Nevertheless, his statement will be believed by many. It is difficult to overcome the sensationalism of the bold and immediate headline with a small retraction on some back page.
This segue from the York affiliation to deaths by chiropractic neck manipulation was very purposefully designed to implant a significant fear into anyone reading the article about stroke, or for that matter, anyone considering a visit to a doctor of chiropractic. There was no evidence to support the statement, save for the guesstimate of one neurologist. The case of a death in Toronto was exploited, even though no court had established a causal connection between the unfortunate incident and the adjustment. Conclusions, designed to be deduced by inference and insinuation by the readers, were what the reporters had in mind.
Following the death by manipulation, we go to the next most sensitive area of the consumers' emotional buttons: treating children. From death to children, one could only conclude by deduction that children should not be treated by a chiropractor. The story moves to the entire children's issue. The following list of areas of concern will provide some insight into the depth to which this comprehensive, albeit biased, report takes the reader. Topics include:
This list will give you some idea of the magnitude of the articles discussed. Embedded within each were links to article after article, some from the very pages of chiropractic journals and textbooks. Also included were audio testimonials to support the view of the reporters in broadening the condemnation of chiropractic and to demonstrate the "truth" of their conclusions.
I would suggest that every practicing doctor of chiropractic and student view the material for themselves and in what fashion it was presented to the public.
This matter will not end with one internet report. It will, however, because of the miracles of technology, be able to take on a virtual life of its own. What we do about it will be discussed later.
On the heels of the Canadian controversy, another breaking news story emerged in the United States. This one dealt with medical errors, and the news that "thousands die from medical mistakes" made the headlines; there were even cries for a congressional investigation.
How the mistakes are made was shocking news to many who simply don't know that medical errors are now the eighth leading cause of death, taking more lives than breast cancer, traffic accidents or AIDS. The mistakes range in categories from: 1) misdiagnosis, including the use of outmoded tests and failure to utilize appropriate tests; 2) treatment, including errors in prescribing medication and inappropriate care; 3) prevention, which included failure to provide proper preventive care and follow-up; and 4) miscellaneous, which included equipment failure and miscommunication.
Many DCs expressed glee when the articles appeared, as if the notion of medical errors somehow justified, corrected or negated the allegations made against chiropractic. Nothing could be further from the truth! The negative facts surrounding medical errors cannot be translated into anything positive about chiropractic. Such an argument is a non sequitur, which cannot and should not be used to defend the value and worth of chiropractic. Logic and reasoned thinking will demonstrate the irrationality of the argument.
Doctors of chiropractic should make their patients and communities aware of this issue, but in a manner that engenders and fosters credibility upon the DC as a valued and respected member of the health care community. Some have said that the number of deaths due to medical errors is the equivalent of crashing a 747 jet full of passengers every day for a year, but that is a meaningless analogy. It is, however, valid to raise the question of why there has not been more attention paid to this epidemic of medical errors, particularly when one witnesses how some journalists in Canada have sensationalized one death in Toronto.
No death occurs without the personal pain and sorrow of those involved, yet a disproportionate focus on the "chiropractic" issue has fueled an emotional frenzy of inflammatory and disingenuous reporting. Conversely, articles appear with an almost apologetic explanation by supporters of medicine outlining reasons for the medical errors and deaths. Some articles suggest that medical doctors work under mountains of guidelines and onerous quality improvement programs. The authors of these articles plead with the reader that the atmosphere should not be a knee-jerk punitive action, but to view and understand these "systems failures" and work to solve them. Shouldn't this be the atmosphere and cooperative environment everyone should be working under? Yet the chiropractic profession gets "tied to a stake" which is ignited by the sparks fueled by the lack of objectivity of the reporters, all while the controversy surrounding medical errors is bathed in a sea of soothing editorial copy without retribution.
For those of you who have not read some of the stories, I would suggest that you obtain a copy of the December 3, 1999 issue of USA Today dealing with "medical accountability," and the September 12, 1999 series that appeared in the Philadelphia Inquirer. These will at least provide you with some background on this current debate and ammunition for future exchanges.
What options are available to us as we reflect on a systematic, comprehensive strategic plan for combating this kind of attack? We can, as we have in the past, deny any allegations or misrepresentations, simply chalking them off to bias, intolerance, discrimination, prejudice or yellow journalism, and go on our merry way, oblivious to the fact that the very foundation of the profession is being challenged. Is that a reasoned approach or solution?
Another option is to gleefully gloat that medical errors are killing thousands of people each year, which may divert the "heat" and focus away from chiropractic for the time being. How does that help advance the chiropractic cause? I hope that as we begin this new year, we try to identify what it is "we" do that creates this backlash against chiropractic and the hypothesis upon which we practice.
Over the years, doctors of chiropractic (including myself) have made unsubstantiated claims for unproven methods. Until we recognize this basic and fundamental fact, we will continue to foster and encourage attacks upon chiropractic. To make claims for which there is no evidence is simply unscientific. Using that approach will never advance the chiropractic profession, but will provide our detractors with ammunition to launch continued attacks at chiropractic.
In our zeal and enthusiasm to advance chiropractic, we have perhaps been too careless and cavalier in our defense of what we do and what we can prove. We have unwittingly used arguments which only foster an unscientific model; and we have been far too careless in our rhetoric, which may be fine for a one-to-one patient encounter but is inadequate when written and carefully scrutinized.
Dr. C.O. Watkins stated:"Let's be bold in what we hypothesize, but cautious and humble in what we claim." Let that be our mantra for the chiropractic profession. The value of what we do every day as clinicians is not denigrated when we use the legitimate language of science.
Does that mean that clinicians cannot use unproven methods? Every practitioner in the world uses unproven methods; that is why we "practice." This is the privilege we have as licensed practitioners of the art, philosophy and science of chiropractic. We can justify treating patients with methods that have not been scientifically validated on an individual basis. What we cannot do (and should be more aware of) is make claims for unproven methods. Therein lies the clinician's dilemma. We see many patients each day, and through whatever regime we decide in concert with the patient, we often have seemingly miraculous results.
For many practitioners, including myself, the rigors of scientific validation are often complex, confusing, confounding and very difficult to incorporate into clinical thinking. The language of science is not easy to incorporate into our everyday clinical activities, particularly when we daily encounter patients wanting help and a promise of hope. Conversely, we encounter those who attempt to destroy the profession with little regard to the benefit millions derive from our care.
I am writing this column to suggest that we resolve not to lash out at those who seek to discredit the profession with documents and statements that we have provided as ammunition for their weapons and that we seek to completely eliminate making unsubstantiated claims. I am making a resolution to try to become more sensitive to the issues surrounding the reasons why the profession is easily attacked.
We provide too much ammunition to those who would use our writing and speeches to discredit us. Often in our quest to address the challenges that confront us, we mix belief with facts and clinical evidence with research validity. We are aroused by emotional rhetoric and invigorated by the motivational eloquence of charismatic orators. There is nothing wrong with a touch of emotion, provided it is tempered by facts and grounded in science. One can still get excited and enthused without undergoing a lobotomy.
Chiropractic must become more aware of the significant distinction between "using" unproven methods in clinical practice versus "making claims" for unproven methods. It can be difficult to fully understand and internalize that distinction, because on the surface it may appear as double talk. When carefully examined, however, it begins to make all the sense in the world.
Can chiropractic eliminate medical errors by attacking medicine? No. Will we advance the cause of chiropractic by attacking medicine? I don't think so. Can we eliminate the criticism of chiropractic as it appeared in the Canadian internet report? Not if the intent of the reporters was biased. However, we can prevent our own statements from being used against us.
When we begin with a better understanding of the distinction between what we do in clinical practice and what we claim happens because of what we do, it will go a long way toward eliminating the criticism. Each doctor of chiropractic must understand that with today's modern technology, what a DC says in some remote part of the world becomes available to everyone instantaneously. The arrival of the internet has changed our world forever. No DC can forget that what he or she says or does will reflect upon the entire chiropractic community. When each of us realizes that, we will have taken the first step in advancing the profession to new heights of understanding.
Will it be easy? No! We need a beginning: a new frame of reference by which to promote the profession. We need less emotional rhetoric and diatribe, and more rational thought, reasoned analysis and professional commentary. We simply need to review our hypothesis and then attempt to develop the appropriate manner of explaining what we do and why, in language that engenders confidence and produces the outcomes we desire.
Thus, my hopes for 2000 are: to reframe our battles; to rethink our approach; and to reinvent and reframe our response to outside criticism. Chiropractic is truly a wonderful and rewarding profession. That we "touch" as part of our therapeutic approach has differentiated our approach and caused many to seek our services. The world is moving toward a paradigm consistent with what we have hypothesized and what chiropractic has tried to explain, often without success. Perhaps we need to rethink our explanations and frame them in language consistent with the universal language of science. While we may not have all the science to support our profession, we have enough of a track record to enable us to practice with competence, undertake research with conviction, and explain chiropractic with confidence.
I hope this article will provide the basis for a lively discussion on the methodology we need to adopt in order to advance the profession. With every opportunity I have in any role, my goal for the immediate future will be to turn down the unsubstantiated claims and turn up the effort to reinvent our image, effectively disarming the CANOEs of the world by removing their ammunition.
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