Space City Skeptics

The Official Blog of the Houston Skeptic Society

Skeptical Pearls #1: If It’s Too Good To Be True…..

with 15 comments

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

Advertisements

Written by skepticpedi

February 27, 2009 at 9:16 pm

15 Responses

Subscribe to comments with RSS.

  1. This skeptical ‘pearl’ is written from a remarkably biased position and one that presumes Western medicine is largely scientific.

    I find it very sad to see this type of old-style evangelical practitioner-bashing still evident in today’s world.

    Phillip Ebrall

    February 28, 2009 at 2:01 am

  2. Thanks for the comment Phillip. I find it sad how quickly people claim bias against a firmly held belief whenever someone speaks out against it, rather than provide any true counterarguments. And speaking of bias, your use of the bogus term “western medicine” should immediately raise a red flag regarding yours. Your comment is a classic example of what had gone wrong in medicine, and to a larger extent in society. People who attempt to rationally speak out against healthfraud and quackery are made out to be biased, defensive, or even elitist. Please provide some kind of cogent argument in support of what you believe, or in refutation of my post, or go home.

    Oh yes, the old “western medicine isn’t really scientific” canard. You need to keep up with the latest anti-medicine propaganda Phillip because that one is equivalent to claiming evolution doesn’t exist because it violates the 2nd law of thermodynamics or, perhaps even more appropriate, that evolution can’t have happened because there are still monkeys swinging through the trees.

    Skepticpedi

    February 28, 2009 at 6:50 am

  3. Medical doctors are the ones who cut the wrong leg off, aren’t they? Hmmm, why don’t you compare the medical malpractice insurance rates of medical doctors versus chiropractors? How about the dollar amounts of lawsuit claims of MD’s versus chiropractors? How about all of the life threatening prescripions they write? What about all of the people who never wake up from surgery? What about all the misdiagnosis? Oops, nicked the aorta, sorry….

    ridgewoodnychiro

    February 28, 2009 at 7:25 pm

  4. Earth to Houston…Houston can you read…?

    ridgewoodnychiro

    February 28, 2009 at 7:26 pm

  5. I apologize for not responding in the one minute between those comments ridgewoodnychiro. I’ll try to do better in the future should you choose to respond but your expectations may be a tad unrealistic.

    Your comment contains a classic example of the tu quoque logical fallacy. Medical doctors and surgeons make mistakes and nobody, certainly not me, is denying that obvious fact. But the reality of medical errors does not effect the reality that there is a dirth of legitimate evidence in support of the efficacy of chiropractic for any non-musculoskeletal condition, and the evidence for that narrow spectrum of ailments is poor at best. It also does not impact on the complete lack of evidence in support of the existence of the subluxation, the core entity around which chiropractic revolves.

    Your concerns, while they do bring up valid issues regarding medical mistakes, are merely an attempt to distract us from the issue at hand. This isn’t a discussion of medical errors, it is a discussion of the problems with chiropractic philosophy and practice. There are many people working very hard to improve medical practice, and there have been huge advances in recent years. I do thank you, however, for allowing me to make the point that in contrast to medicine, there is precious little, if any, attempts by alternative medicine practitioners at quality control. Science changes in response to new evidence while proponents of alt med dig in their heals and refuse to give up firmly held beliefs.

    Your comments regarding malpractice are more non sequiturs that do not count as a rational rebuttle. But I will ask this: What about all of the people that would suffer morbidity and/or mortality in the absence of medical care. Ignoring the denominator in discussions like this is a classic ploy and it won’t fly here.

    skepticpedi

    February 28, 2009 at 11:46 pm

  6. […] to Houston… https://spacecityskeptics.wordpress.com/2009/02/27/skeptical-pearls-1-if-its-too-good-to-be-true/ Possibly related posts: (automatically generated)Zions Bankcorp is bleeding…AMEGY […]

  7. I would recommend that ridgewoodnychiro read “Trick or Treatment” and then discuss the research presented there.

    I submit that chiropractors don’t need medical malpractice insurance because they don’t practice medicine.

    Geek Goddess

    March 2, 2009 at 11:09 am

  8. On the chiropractic malpractice insurance issue:

    The basic reason that malpractice insurance for chiropractors is less expensive than that for doctors is driven by the bottom line for the insurer, that being the averages associated with paying out on malpractice claims (i.e., the frequency of claims and the amounts paid per claim). I suggest there are a number of reasons the averages here are lower for chiropractors than they are for doctors:

    (1) The types of injuries/illnesses involved – as a general proposition, a patient with a severe or life-threatening injury or illness is more likely to go to a doctor than a chiropractor, so there is more at stake if there is a negative outcome.

    (2) Objective criteria for evaluating efficacy of treatment – because doctors rely on science for purposes of diagnosis and treatment, when a patient has a negative outcome the evaluation of what caused the outcome is relatively simple and evaluation of whether or not the doctor’s treatment of the patient was effective or not is relatively easy to demonstrate. By comparison, a chiropractic patient who has a negative outcome has a much greater hurdle to overcome in demonstrating causation because chiropractic treatment has precious little in the way of objective measures for determining whether treatment was effective.

    (3) Standard of care – as a byproduct of (2), above, it is much more difficult to find a source of evidence for establishing a breach of the standard of care for a chiropractor than it is for a doctor. A chiropractor is held to the standard of what another reasonable chiropractor would have done under the same circumstances, not the standard of what a doctor would have done under those circumstances, and since chiropractic care has much less rigorous standards for evaluation and treatment it is far more difficult to establish that a chiropractor wasn’t sufficiently careful.

    (4) Regression to the mean – because the injuries or illnesses treated by chiropractors tend to be much less severe (see (1), above), they also tend to be self-limiting. A relatively minor soft tissue injury is going to heal itself over time no matter what treatment is used, so from the patient’s perspective he or she was injured, went to the chiropractor and got better with time, so the patient has no reason to claim that the chiropractor did anything wrong.

    (5) Relative innocuousness of treatment – most chiropractic treatment is relatively unlikely to injure the patient or make his or her condition worse (though recently evidence was found of a correlation between chiropractic treatment and stroke risk, which will likely over time translate into more frequent and more costly claims). The treatments used by doctors often have more associated risk because they actually have an effect on the patient, which is the cost of employing treatments that are actually effective.

    Mark

    March 2, 2009 at 11:25 am

  9. Thanks for that excellent synopsis Mark. Your comment supports my contention that bringing up malpractice rates and payouts was a non sequitur and done in an attempt at diversting readers from the real issue. That is assuming that the commentor has ever given any actual thought to the subject rather than just memorized anti-medicine propaganda talking points.

    skepticpedi

    March 2, 2009 at 12:20 pm

  10. I’m a chiropractor, and although I winced several times while reading it, I agree with some of the main premises of this article. I would also like to dispute Mark’s comment (5) above.

    There are some pretty disgraceful marketing practices employed by chiropractors, no doubt. As a profession, we’ve done a terrible job defining our scope of practice, standardizing our treatment methods, and even qualifying vs. disqualifying candidates for our care. We can do better with our professional unity.

    Still, I think we are the number one “alternative medical modality” in this country for a reason. *People really like the way they feel when their joints are working well.* It’s more than just pain relief for the vast majority of my patients.

    My dream for myself and fellow chiropractors is that we focus on outcome-based treatment and get really clear with our patients about their treatment goals. Acceptable non-pain relief outcomes might include something as specific as increased range of motion in the low back, or something as intangible as, “I feel like I can golf all 18 holes now”. Our profession has matured greatly since the 1800’s, although we have a ways to go. We have made great strides in documenting our effectiveness for more than just acute lower back pain, as articles in the peer-reviewed journals JMPT and Spine reveal.

    Regarding Mark’s comment above, “though recently evidence was found of a correlation between chiropractic treatment and stroke risk, which will likely over time translate into more frequent and more costly claims”

    The most recent evidence shows quite the opposite:
    “The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.”

    Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study. Spine. 33(4S) Neck Pain Task Force Supplement:S176-S183, February 15, 2008.

    Dorothy Ponton, DC

    March 2, 2009 at 5:54 pm

  11. Dorothy, have you read the book “Trick or Treatment”? The authors did a meta analysis on chiropractic testing and double-blind studies, and come to some interesting conclusions, not all negative towards some chiropractic treatments

    GeekGoddess

    March 2, 2009 at 7:31 pm

  12. Dorothy Ponton wrote,

    “Still, I think we are the number one “alternative medical modality” in this country for a reason. *People really like the way they feel when their joints are working well.* It’s more than just pain relief for the vast majority of my patients.”

    People tend to feel good after a massage as well but I wouldn’t want the person giving it acting as a patient’s primary care provider or offering to treat their child’s autism.

    The ways that a person can be convinced that a therapy is working for them, or that the therapy they are providing is working for others, are numerous and have nothing to do with actual efficacy of the therapy. Basing your conclusion on what amounts to a bunch of anecdotes is essentially meaningless. A large part of chiropractic’s perceived efficacy is simple placebo, something which is easily brought about by the laying on of hands done in the chiropractor’s office, the use of a novel therapy, regression to the mean, etc, etc. Most of the rest stems from the fact that many chiropractors provide standard physical therapy. There is no good evidence that anything chiropractors do is effective in treating anything non-musculoskeletal, and the evidence in support of non-musculoskeletal maladies is weak and tends to be published in journals like JMPT.

    As far as evidence you are touting goes, recent doesn’t always mean better. Being better designed to answer a particular question is all that matters. What you are referring to above was published in a supplement to Spine and was obliterated by Mark Crislip over at Science-Based Medicine:

    http://www.sciencebasedmedicine.org/?p=170

    skepticpedi

    March 2, 2009 at 7:32 pm

  13. GG,

    That book is on my list to read. I will say that I heard an interview given by Singh and was concerned. I can’t recall the specifics but he was naive about a few things. I’ll try to find the interview, I think it was on NPR recently.

    skepticpedi

    March 2, 2009 at 7:35 pm

  14. Thanks, “Trick or Treatment” is on my reading list now.

    Checked out sciencebasedmedicine.org.

    Dorothy Ponton, DC

    March 2, 2009 at 8:22 pm

  15. Dorothy Ponton, DC said:

    “Still, I think we are the number one “alternative medical modality” in this country for a reason. *People really like the way they feel when their joints are working well.* It’s more than just pain relief for the vast majority of my patients.”

    There are a number of factors I would suggest explain why chiropractic is the most popular alternative medical modality in the U.S.:

    (1) Some benefit from treatment – credit must be given where it is due. Chiropractors can and do employ some treatment that is the functional equivalent of physical therapy, which does have a demonstrable benefit.

    (2) Insurance coverage – insurers are willing to pay for chiropractic treatment of soft tissue injuries, I suspect in part because the negotiated rate for chiropractic treatment is less than equivalent treatment from a physical therapist (see (1), above). The patient has less out-of-pocket cost than he or she would from financing treatment complete on his or her own, so it’s a more attractive option.

    (3) Apparent legitimacy – A number of factors give chiropractors and chiropractic treatment an apparent legitimacy and equivalent dignity in comparison to medicine. Chiropractic treatment has been around for over a century, during which time it has enjoyed the status of being a mainstream form of treatment. Chiropractors must be licensed. Chiropractors employ many of the trappings of medicine, such as lab coats, X-rays, documentation of diagnosis and treatment, etc. All these factors give the patient a sense that the chiropractor is knowledgeable, wise, and can be trusted to administer effective treatment. Though I list this as the third factor here, I think that this is probably the single most important factor for explaining why chiropractic is so popular compared to other alternative treatments.

    Mark

    March 3, 2009 at 10:14 am


Leave a Reply

Please log in using one of these methods to post your comment:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: