Skeptical Pearls #1: If It’s Too Good To Be True…..
One of the more common approaches that attending physicians take when teaching medical students and residents is the use of clinical pearls. Rather than cold, hard facts, such as the most common form of congenital adrenal hyperplasia being 21-hydroxylase deficiency, these pearls of clinical wisdom are more akin to generally accepted rules of thumb. My personal favorite example is the admonition to avoid poking the skunk. Poking the skunk occurs when labs are ordered which aren’t necessary in the care of the patient. Checking a basic metabolic profile when all you really need is the serum sodium is risky. In fact, it seems that the less vital a particular lab value is to management decisions, the more likely it is going to come back as falsely abnormal, which often leads to further unnecessary tests. I don’t like to stick needles in babies, although you might not think that if you spent a day with me at work, so this particular clinical pearl comes up pretty often on my rounds.
I also make a point, on an almost daily basis, to incorporate pearls of critical thinking into my teaching of medical professionals in training. Naturally, these tend to focus on my particular area of interest, the myriad and often contradictory therapies falling under the umbrella term alternative medicine. As I’ve said many times before, I prefer terms like unscientific medicine, or quackery to be quite honest, over alternative medicine, integrative medicine, or complementary medicine. These are manipulative marketing terms used to lull the general public into acceptance with a false air of legitimacy, and the academic community into the application of a double standard to the evaluation of safety and efficacy of these therapies. There is only one legitimate means of determining whether a treatment works, and that is with science.
One example of a very helpful critical thinking pearl that should be applied to the claims of a large number of so-called alternative approaches to health, is that there is often an inverse relationship between the number of symptoms or conditions supposedly treated by a therapy and the number that is actually treated. This is better expressed with the adage that if something is claimed to cure everything, it almost certainly cures nothing. The number of alternative medical modalities that fall into this category are numerous and experiencing seemingly exponential growth, however the most important example because of its acceptance by the general public as a legitimate and science-based practice is that of chiropractic.
Though nobody, even chiropractors themselves, have been able to define themselves in a way that allows a consistent and practical understanding of just what it is that they do, there are some safe generalizations which can be made. For instance, they tend to be spine-centered rather than the oft advertised “holistic”, and a significant percentage of them categorize themselves as “straight”. This distinction shares a dichotomous relationship with self-described “mixers”, which as the name implies are prone to incorporating a wide variety of decidedly non-spine centered therapies into their practice such as acupuncture, applied kinesiology, or nutritional supplementation, as well as some science-based modalities like standard physical therapy. Mixers outnumber straights by a large margin, and though they do make use of other therapies, they still primarily focus on the correction of a non-existant entity known as the subluxation.
Subluxations in the chiropractic sense, as opposed to the legitimate medical diagnosis, are as polymorphous as one would expect of something invented out of whole cloth* by a former magnet healer and spiritualist over a hundred years ago. Since 1895, the term has evolved into many different forms with all stages still believed in by varying numbers of chiropractors today. The manifestation which likely is accepted by the largest number of currently practicing chiropractors involves a proposed “complex of functional and/or structural and or pathological articular changes that compromise neural integrity and may influence organ system and general health”. This definition is so slippery as to be rendered utterly meaningless, and is a prime example of the inability of chiropractors to be able to establish a standard definition of who they are and what they do. This fact actually benefits chiropractors however, as it allows for a near limitless scope of practice and the ability to bill many insurance companies for the treatment of a phantom condition.
Regardless of whether a chiropractor is a straight or a mixer, they are likely to claim that they have special insight into your particular complaint regardless of what it is. With rare exception, chiropractors assert their ability to treat not just common musculoskeletal complaints, a category of conditions falsely considered by many to be their area of particular expertise, but the entirety of known medical maladies. Many will even treat one or more of a growing number of fictitious conditions such as adrenal fatigue or Wilson’s Thyroid Syndrome. This is often done overtly with outright claims of personal success in curing conditions ranging from asthma to zoster, with some even touting their ability to treat serious life-threatening illnesses like cancer and HIV.
Straight chiropractors take a different approach, boldly claiming only to treat subluxations, which then allows for the innate healing power of the human body to heal any disease state under the sun via an unimpeded spinal conduit. A critical evaluation of the medical literature reveals a far different reality however. After a little over a century of existence, there is essentially no good evidence that chiropractic care is effective in the treatment of any medical condition, or any made up one either. The one sliver of an exception is the treatment of acute lower back pain, which does appear to resolve under the care of a chiropractor. What they may not want you to know is that it has not been shown to work any better than more standard treatments such as physical therapy and the use of ibuprofen.
*The top link on google when inserting the phrase “invented out of whole cloth” takes one to an article on the history of chiropractic