Staring at me was my schedule: My first Dynamic Chiropractic article of the year was due.
One of the articles Dan most recently sent came from the May 2003 issue of the British Medical Journal (BMJ): "Who Pays for the Pizza? Redefining the Relationships Between Doctors and Drug Companies."1 It deals with the ethical relationship of medical physicians and pharmaceutical companies, and how what may have started out as seemingly innocent programs, turned into "influence-peddling" at the highest level. I sent the article to our local medical staff and hospital board of trustees, so they could maintain awareness of what is going on (overtly or covertly) to increase drug consumption in this country - based on a motivation of corporate greed, rather than patient need.
Yes, chiropractic can take some solace in its long history as a profession that espouses nondrug, nonsurgical health care (and even this historic position may be changing, as some chiropractors are beginning to recommend over-the-counter pharmaceuticals). However, there is little comfort in condemning the medical/drug cartel, while at the same time ignoring the obvious transgressions within our own professional house.
An obvious, often conveniently overlooked fact is that we (the chiropractic community) do not often give acknowledgment or recognition to the authors of probing, skeptical, self-critical articles published in medical journals (in this case, BMJ). The NEJM and JAMA have, in the past, also published articles and editorials containing harsh criticism of the medical profession, condemning their actions, ethics and behavior, and exposing their shortcomings and weaknesses. This kind of action is the mark of a profession, as well as positive proof of the determination of self-regulation, which is vital to avoiding mandated governmental oversight.
Can you imagine the kind of backlash and indignation that would result if Dynamic Chiropractic, the ICA Review, the Journal of the ACA, or Chiropractic Economics wrote a scathing expos or critical article dealing with some ethical, clinical, professional or business aspects of chiropractic? An outcry of righteous indignation demanding the editors be "tarred and feathered" would soon begin. Some within the profession would regard the authors and their publications as nothing short of traitors. Canadian DC Jaroslaw Grod and his co-authors have tasted just such a backlash for their criticisms of the unsubstantiated claims made by various chiropractic organizations.2 Fortunately for them, but not for the profession, few chiropractors subscribe to or read JMPT. The critique, Bonesetting, Chiropractic & Cultism,3 earned its author, Sam Homola, DC, a 30-year exile from the profession. Chiropractor John J. Nugent's 20-year quest to critique and improve chiropractic education earned him a forced retirement and scorn as the "Antichrist of chiropractic."4
We simply do not permit internal critical review of any aspect of chiropractic without repercussion and ad hominem attacks on the author. Yet ironically, DCs are quick to jump on any article in the medical literature critical of their own profession; we joyfully display such articles as proof that "chiropractic is right," as evidenced by the conclusions arrived at in the medical article. When an article containing critical commentary about a chiropractic technique, device, procedure or approach is challenged, however, the profession seems impervious to self-scrutiny.
Just take a close, critical look at some of our own publications; it will become quickly evident that ethical conflicts exist between the publications' editorial and advertising policies. There are clearly questionable activities (some cleverly disguised) between these policies and business interests. It should be painfully obvious to any reader that this conflict exists - and hopefully, this awareness influences the veracity and validity of the subject matter.
This kind of unethical activity needs to be exposed by the chiropractic profession for what it is, and written about to ensure admission, or at least full disclosure, from the publication, in order to clarify future editorial content from advertising content. This disclosure, if properly exposed, can then be discussed, deliberated over and recognized by the profession. When the lines blur between pure information and self-interest, only recognition, detection, exposure and disclosure will enable the reader to fully understand the context of the message. Also blurred in this entire process is the potential economic gain from the advertising and sales of equipment of questionable diagnostic value, yet it is promoted in publications in which editorial space and financial interests conflict.
Schemes and scams, irrespective of how cleverly designed and persuasively written, are still schemes and scams. Advertising headlines claim to increase patient visit averages to "hundreds" and make "patients love you," or to free the DC to "work less and earn more." One claims guidelines to "free yourself of responsibility as a doctor" while practicing "any way you want" (yadda, yadda, yadda ...). The hype and propaganda is a never-ending source of amazement, embarrassment, exploitation and confusion. These need to be recognized and exposed from within the profession, rather than wait until some external source - the government, than wait until some external source - the government, law enforcement, third-party payer or insurance company - exposes the misconduct for us.
Taking a closer look at the BMJ article that caught my eye, it soon becomes clear that the list of "ethical entanglements" outlined in the article is very comprehensive. Here are a few of the ethical considerations listed as potential ways doctors and drug companies can get into problems:
- the acceptance of indirect gifts by doctors, through sponsorship of software or travel;
- providing doctors/researchers with ownership of stock or equity holdings;
- doctors undertaking paid consultancies to work for drug companies;
- providing membership on company advisory boards of "thought leaders";
- doctors conducting company-sponsored research;
- doctors involvement or use of pharmaceutical-sponsored clinical guidelines; and
- doctors' having articles ghostwritten by drug companies and then published by pharmaceutical companies as original articles.
According to the BMJ article, in Italy, it is now seen by some legal authorities as bribery to "wine and dine" physicians. Strong and consistent evidence shows that drug industry-sponsored research tends to draw conclusions favorable to industry, and industry-sponsored studies are more likely to reach conclusions that were favorable to the sponsor than were most non-industry studies. Is any of that going on in chiropractic?
The BMJ article is a worthwhile read. As for the chiropractic profession, isn't it about time we began a systematic review of programs, issues, practices and articles that are simply wrong, unethical, questionable, dubious, suspicious, unprofessional - or simply downright absurd - and begin to expose them in our own publications?
Isn't it about time we provide incentive and acclaim to the authors who have the courage to expose injustice, fraud or unprofessional conduct? Perhaps someone should start a journal titled The Journal of Unprofessional Behavior. I really hope this slightly exaggerated suggestion for a publication will never be necessary.
The BMJ article also stated that the pharmaceutical sales force alone exceeds 80,000- a greater number than the entire chiropractic profession practicing in 2003! The issues within the article have far-reaching ramifications for the chiropractic profession. These will serve as excellent concepts for future articles in 2004.
We won't solve the issues with this article; however, January is a good time to consider its points in relation to New Year's resolutions. As for the article, "Who Pays for the Pizza?" - no matter how you slice it, if it is not made with ethical ingredients, we will all pay!
- Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. BMJ, May 2003;326:1193-6.
- Grod J, Sikorski D, Keating JC. The unsubstantiated claims of the largest state, provincial and national chiropractic associations and research agencies. Journal of Manipulative & Physiological Therapeutics, Oct 2001;24(8):514-9.
- Homola S. Bonesetting, Chiropractic and Cultism. Panama City FL: Critique Books, 1963.
- Gibbons RW. Chiropractic's Abraham Flexner: the lonely journey of John J. Nugent, 1935-1963. Chiropractic History 1985;5:44-51.
Louis Sportelli, DC
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