There is an apocrypha about a young man who received a letter from an executive of a large corporation, signed, "Dictated but not read." The young man thought this was quite powerful, assuming that such a comment below the signature denoted importance.As a result, when he replied, he typed at the bottom of his letter, "Dictated but not read." He was trying to get an internship at the company. Unfortunately, his reply letter provoked an angry response from the executive, who felt it was disrespectful from someone seeking a favor (the internship). As a result, the young man lost the opportunity he had been offered in the original letter.
The young man realized this "power move" had consequences. Likewise, doctors who send out their medical record with "Dictated but not read" may believe that this absolves them of legal responsibility for the correspondence their office sends to insurance companies, when in fact, the consequences of such correspondence are no better than if they had actually signed it after reading what they had "dictated."
We suspect that many chiropractors buy premade practice websites, thinking it is more important to have enough content than quality of content. In a study of chiropractic wellness information on the web, approximately 50 websites were reviewed.1 Most of them came from a limited number of vendors and as a result, the content of many of the doctors' websites were virtually identical. The main differences were the practice and doctor's name, the photo of the doctor(s) and their office(s).
The study found there was precious little on these websites about real wellness. Most of the content was about how wellness comes from getting treated over and over, not from behaviors the doctor(s) would teach the patients: decreasing fat intake, increasing exercise, wearing a seatbelt or helmet, drinking in moderation, smoking cessation, abstaining from "recreational" drugs, etc.
How many of the doctors really knew what "their" website said? Did they actually read all that content they'd bought? We're sure some do and either believe what the website says or don't think it matters too much. But it also seems likely that many just buy the website because it looks good and has a lot of content.
One of my very close friends moved to a new state and bought such a canned website. Reading some of the contents of his web site would make one believe that the doctor had made a 180-degree change and transitioned from an evidence-based chiropractor to a subluxation-based one. Not that such a transition hasn't happened (and vice versa), but it just didn't seem as if that was a change he, of all people, was likely to make.
When I queried the doctor, he said he hadn't really read the content of the website he'd bought. With all the time sinks for someone who'd moved their family and started a new practice in a different part of the country, he didn't have the time and was just happy to have a "shiny new" website to announce his presence in the community.
However, there are examples of serious consequences when a website posted to the web, but not read, or maybe read and believed – but unbelievable. Likewise, significant problems can arise when using advertisements that aren't verified for their validity, such as some of the claims about the clinical effectiveness of "decompression" (AKA expensive traction) equipment.2 In Oregon, the Attorney General's office went after the company that manufactured the equipment and a chiropractor from another state who marketed promotional materials for chiropractors to use. In a press release, the AG [at the time, Hardy Myers] wrote: "Oregon chiropractors must do their own homework before purchasing and promoting medical devices. Medical professionals cannot simply rely on the sellers' claims without investigating for themselves."3
A search of regulatory board actions in many jurisdictions is likely to reveal action against individual licensees for the content of their websites or other advertising. Many jurisdictions have statutes or regulations that mandate the validity of the content.
Not commonly known in North America is what happened in the United Kingdom a few years ago. A "skeptic" activist wrote a program to search the websites of every chiropractor in the U.K. This program searched these websites to find if there was any mention of colic. The activist then read those pages to determine if there was a claim to treat colic.
He found something about treating colic on 160 websites representing approximately 800 chiropractors, more than half of all chiropractors in the U.K. Then he filed complaints with local authorities (Trading Standards) who ensure the validity of advertising claims; and with the General Chiropractic Council (GCC), the regulatory authority for chiropractic in the U.K. (similar to the U.S. state chiropractic boards or in some Canadian provinces, colleges of chiropractors).
The GCC was overwhelmed with more than 800 complaints, all relating to claims made on websites on what chiropractic could treat. The regulatory rules at the time stated that all advertising by the profession had to meet the Advertising Standards Authority (ASA). The ASA rules said that all claims had to be backed up by what it considered the highest level of evidence: the "randomized control trial."
A tiny proportion of the chiropractors were found guilty of misleading the public, a number of them with the same "canned" websites, but the consequences to the profession were immense.
Ultimately, this action cost the profession around 1.4 million pounds. The publicity was already at fever pitch following the action of the British Chiropractic Association bringing a claim for slander against Simon Singh, which it eventually lost on appeal. Singh, a journalist, had claimed that there was not a "jot" of evidence for chiropractic. He was able to muster huge support in the press; for awhile, articles were being published daily about the dangers of chiropractic.
Patients already struggling financially in the recession stayed away from chiropractors, resulting in many practices closing their doors for good. Those chiropractors who chose to defend themselves at a hearing had to hire barristers at a huge cost to themselves. The GCC decided to commission a systematic review to get a picture of the evidence base for a range of conditions chiropractors claim to treat and found it woefully inadequate.4
Is it OK to say, "I treat colic successfully; therefore I can advertise it?" Not in the U.K. That said, should we totally discount clinical observation? Many chiropractors help conditions for which a biologically plausible mechanism for a specific effect is not clear. Manual therapies are characterized by the use of hands, so any consideration of the effectiveness of such treatments must take into account such things as the interaction between the chiropractor and the patient, which may have a therapeutic effect.
Can we effectively measure this in an RCT? We should be looking at different ways of measuring our effectiveness to put our critics to bed once and for all. It is important to remember that absence of evidence of effectiveness is not the same as evidence of absence of effectiveness.
Providing a treatment that has been shown to be ineffective – or for which there is insufficient evidence when there are other options that have been shown to be beneficial – is not appropriate, nor is it appropriate to make claims of effectiveness when there is no evidence to support such a claim. It is important to remember that at a time when the profession seeks to be an authority in musculoskeletal medicine, it is imperative that the profession looks to the best available evidence and practices such.
We are sure some reading this are thinking, "I successfully treat colic regularly; what's wrong with that?" Different jurisdictions have different regulations when it comes to advertising. Some jurisdictions, like the U.K., need more than anecdotes; they need research to document claims of effective treatment. Doctors should determine the standards in their jurisdiction, as our licenses don't allow us to have websites that are posted but not read.
- Evans MWJ, Perle SM, Ndetan H. Chiropractic wellness on the web: the content and quality of information related to wellness and primary prevention on the Internet. Chiropr Man Therap, 2011;19(1):4.
- Perle SM. "Good Advertising." Dynamic Chiropractic, Sept. 10, 2007.
- "AG Stops Out-of-State Companies From Using ‘Junk Science' to Promote Chiropractic Devices: Oregon Chiropractors Disseminated Deceptive Advertisements." Press release, Office of the Attorney General, State of Oregon, dated June 28, 2007.
- Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat, 2010;18:3.
Click here for previous articles by Stephen M. Perle, DC, MS.
Dr. Jatinder Benepal graduated from the Anglo-European College of Chiropractic (AECC) in 1986 and received her postgraduate diploma in chiropractic orthopaedics and rehabilitation in 1992. She is the proprietor of ISIS Chiropractic Clinics, a group of three clinics in Buckinghamshire and Northamptonshire. She has previously held a number of positions in the British Chiropractic Association (BCA) including secretary, PR committee chairperson and communications director; and served on the committee that developed the 1994 Chiropractors' Act with the U.K. government. Following her election in 2006, Dr. Benepal is currently director of international affairs for the Royal College of Chiropractors and also chairs the marketing committee.