You may recall the Dec. 1994 publication of the practice guideline Acute Low Back Problems in Adults from the Agency for Health Care Policy and Research (AHCPR).1 The panel responsible for that document was composed of 23 experts (whittled down from 200 nominees) who selected over 100 peer reviewers to evaluate the literature.They reviewed the exhaustive evidence-based guidelines from the 1984 Quebec Task Force on Spinal Disorders, plus 10,317 abstracts published after 1984.
The AHCPR panel found manipulation to be "safe and effective for patients in the first month of acute low back symptoms without radiculopathy."
These prestigious guidelines are compelling to any honest and reasonable observer, but the AMA chose to attack the guidelines, hiring a medical writer and a panel of MDs to quickly write a pocket guide to back pain.2 That guide claimed to cover "the latest information on all treatment options," yet excluded any reference to spinal manipulation. As far as their guidelines were concerned, spinal manipulation didn't exist.
My first reaction was, "How could they exclude the treatment found to be safe and effective by the AHCPR's top interdisciplinary panel of experts? This action by the AMA represents gross misrepresentation by exclusion. I concluded that if the AMA could be that irresponsible and foolish with their guidelines, I would make every effort to expose them on every talk show on which I would appear. The issue of the credibility of the government study is not even arguable. There is no way the AMA can honestly defend what they did.
I realize that the AMA has never had a very honest and honorable record of dealing with chiropractic, but this latest incident was just outrageous and indefensible. The AMA left itself wide open for serious criticism and condemnation that it cannot justify or explain. Yet why did the AMA do it?
Let's put this issue into another perspective. Suppose 23 oncologists, the top experts on cancer, evaluated the cancer research under the auspices of the U.S. Dept. of Health and Human Services; suppose they concluded that surgery and/or radiation were the best treatment options for cancers. Then suppose that after the government published the cancer treatment guidelines, our national associations got a panel of chiropractors together to write their own cancer guidelines, listing all kinds of chiropractic treatments, and then boasting that our guidelines included "all of the latest cancer treatments," while excluding any reference to radiation or surgery. How would the AMA react?
The AMA would become extremely vocal against chiropractic for misguiding the public. Chiropractic would be guilty of fraud by omission or exclusion for not including radiation or surgery as viable treatments. And any chiropractors following the chiropractic cancer guidelines would face malpractice lawsuits.
The AMA and the entire country would look upon chiropractors as irresponsible and dangerous lunatics. We'd be the laughing stock of the nation, and public respect for chiropractic would plummet into the gutter. But the AMA has done precisely the same thing.
Why did the AMA take such an irresponsible and vulnerable position? The AHCPR guidelines were critical of disc surgery. Even "CBS News" was talking about there being 80,000 unnecessary disc surgeries every year. How many unhappy or outraged disc surgery patients suddenly saw an opportunity to take their surgeon to court and have a credible government document to support their complaint? What if they suddenly began contacting our government in mass numbers for copies of these treatment guidelines, then hired lawyers and sued surgeons for not following them?
The AMA had to "defuse" the AHCPR guidelines, or witness a rash of lawsuits. Publishing their own back pain guidelines was designed to neutralize surgery litigation. This appears to be a clear case of protectionism, but it is based on untruths, which compounds the seriousness of the matter.
It appears to me that it is high time our national leadership take off the white gloves and adopt a hard line, demanding a congressional investigation of the AMA for health care fraud by exclusion. The issue transcends chiropractic or medicine. We are talking about appropriate health care by utilizing the safest, therapeutically proper and cost-effective methods for patients.
Call or write to your national chiropractic association and urge them to take action. I'm sure that with our outstanding facts and the great legal counsel that we have at our disposal, the route we take will be appropriate. Meanwhile, send a copy of this column to all of your state and federal legislators and the press. We owe it to our patients and our nation's welfare.
- Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Dec. 1994.
- American Medical Association Pocket Guide to Back Pain: The Latest Information on All Treatment Options, Including Medications, Physical Therapy, and Surgery. Random House, 1995, ISBN 0-679-75560-8.
Chester Wilk, DC
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