Within just the past six months, a very intriguing and revealing succession of articles has appeared in the medical journals, containing many climactic elements of a good drama. First was the announcement in what some might regard as the citadel of orthodox medicine, the Journal of the American Medical Association. The speed with which public sentiment for alternative medicine has grown is attested to by the following. A panel of editors ranked alternative medicine 68th out of 73 topics of importance last year; just recently, however, the panel ranked alternative medicine among the top 3 out of 86 to address in their journals in the coming year.1 What a difference just the past year seems to have made!
Next came a pair of papers which profoundly underscored disturbing trends in the use of medications in the United States. One estimates that the incidence in 1994 of adverse drug reactions was 106,000 (6.7%), making it the fifth leading cause of death.2 The other paper points out that outpatient medication error deaths increased 8.5-fold in the United States in the decade ending in 1993, far greater than the 2.4-fold rise in inpatient medication-error deaths observed in the same time.3
The larger picture from the Phillips study is that it has occurred during a period in which outpatient visits increased by 75% while inpatient days fell by 21%.4 This reflects a milieu in which it has been acknowledged by the medical community that "it is thought to be increasingly difficult for physicians to maintain the continuity and quality of their relationships with patients.5
Only three months later, yet another study appeared in the British Medical Journal which destroyed once and for all the popular notion that 90 percent of all episodes of low-back pain resolve within one month. Rather, low-back pain is aptly redefined as "a chronic problem with an untidy pattern of grumbling symptoms," with only 25% of patients consulting about the problem reporting full recovery 12 months later. Instead, most patients appear to be enduring their pain but not telling their primary care physician about it.6
These findings reinforce the arguments recently advanced by Manga7 to the effect that we need to define episodes of back pain more appropriately, as opposed to the recent methodologies of both Carey8 and Shekelle,9 which I have been able to rebut in one of the indexed medical journals.10 Episodes commonly defined by traditional PCPs are those which they hear about, but if a patient fails to visit them, the problem does not simply go away. This is precisely where chiropractic and standard medical care diverge. The "out of sight, out of mind" operative commonly associated with the latter simply won't cut it anymore.
The common thread running through all these studies has to do with the importance of the patient as the center of all clinical decision-making. Information and communication are the commodities with which all effective current and future medical care must function, regardless of whatever modality and whatever profession is employed in its delivery. The language of chiropractic, described as helping patients visualize their problems within a noninvasive, holistic approach to healing, is especially suited for fulfilling this need by encouraging patient understanding and engagement which directly leads to commitment and fulfillment.11
Salient elements of a patient-centered paradigm (self-healing; recognition of the patient as a unified whole; respect for the patient's values, beliefs and dignity; involvement of the patient as a partner in health promotion; and a natural and conservative approach to evidence-based health care) have recently been identified as intrinsic elements in chiropractic health care by a consensus panel and extensively described by Gatterman.12
With the proper research, it may turn out that the conservative, drugless approach which chiropractic has embraced for over a century will be more widely recognized as being in the patient's best interest. To paraphrase David Eisenberg's recent comments about the nearly explosive emergence of alternative medicine into public consciousness, it will be as if "we had unroofed a hidden mainstream."13
- Complementary, alternative, unconventional and integrative medicine: call for papers for the annual coordinated theme issues of the AMA journals. Journal of the American Medical Association 1997;278(23):2111-2112.
- Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. Journal of the American Medical Association 1998;279(15):1200-1205.
- Phillips DP, Christenfield N, Glynn LM. Increase in US medication-error deaths between 1983 and 1993. Lancet 1998;251:643-644.
- American Hospital Association. Hospital Statistics: The AHA Profile of United States Hospitals. Chicago, IL: American Hospital Association, 1983-1995 (yearly editions).
- Emanuel EJ, Brett AS. Managed competition and the patientþphysician relationship. New England Journal of Medicine 1993;329:879-882.
- Croft P, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. British Medical Journal 1998;316:1356-1359.
- Manga P, Angus D. Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and achieving equitable access to health services. Report to the provincial government of Ontario, February 1998.
- Carey TS, Garrett J, McLaughlin C, Fryer J, Smucker DR, North Carolina Back Pain Project. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. New England Journal of Medicine 1995;333:913-917.
- Shekelle PG, Markovich M, Louie R. Comparing the costs between provider types of episodes of back care. Spine 1995;20(2):221-226.
- Rosner A. Letter to the editor. Spine 1995;20(23):2595-2596.
- Coulehan JL. Chiropractic and the clinical art. Social Science and Medicine 1985;21:383-390.
- Gatterman MI. A patient-centered paradigm: a model for chiropractic education and research. Journal of Alternative and Complementary Medicine 1995;1(4):371-386.
- Eisenberg DM. Alternative medicine: introduction and overview. Alternative medicine: implications for clinical practice. Boston, MA, March 1-4, 1998.
Anthony L. Rosner, PhD
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