MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Informed consent is an essential ethical precondition for any therapeutic intervention. This obviously cannot exclude alternative medicine. Yet, one gets the impression that alternative therapists systematically ignore informed consent. Chiropractors in the UK, for instance, have been shown to often take this issue more than a little light-heartedly.

The General Chiropractic Council (GCC) has issued guidance to its members about informed consent. Here is a passage from their website which I find particularly interesting:

The information you provide to the patient must be clear, accurate and presented in a way that the patient can understand… Patients must be fully informed about their care. You must not rely on a patient to ask questions about their care, the responsibility to fully inform patients about their care lies with you.  When discussing with patients the expected outcomes of their care, chiropractors must fully discuss the risks as well as the benefits and explore with the patient what other factors they may see as relevant to making a decision.

When explaining risks, you must provide the patient with clear, accurate and up-to-date information about the risks of the proposed treatment and the risks of any reasonable alternative options, in a way that the patient can understand. You must discuss risks that occur often, those that are serious even if very unlikely and those that a patient is likely to think are important. You must encourage patients to ask questions, so that you can understand whether they have particular concerns that may influence their decision and you must answer honestly.

I have repeatedly written about the fact that, in alternative medicine, informed consent has remained an almost alien concept. Yet, there can be no doubt, it is an ethical imperative in ALL healthcare. The above guideline makes this perfectly clear. Essentially, it proscribes that a chiropractor has to inform each patient who is about to be treated with a spinal manipulation – virtually 100% of all patients consulting chiropractors – that:

  • this treatment has not been shown to be effective for non-spinal conditions,
  • for back and neck pain, it might help but not better than other conservative therapies,
  • in about half of all patients, it leads to mild to moderate adverse effects that typically last 2-3 days and are severe enough to interfere with the patient’s quality of life,
  • in an unknown number of patients, it might lead to severe complications, including stroke and death,
  • there are other options for your problem that are more effective and/or less harmful.

The chiropractor then has to document the patient’s consent. Only then can he start treatments.

My question to the GCC is: have you tested how many patients would consent under these conditions?

I suspect the answer is No.

And my questions to UK chiropractors is: who is actually following these guidelines?

I suspect the answer is VERY FEW. If that were true, most chiropractors would violate their own ethical guidelines and could therefore be struck of the GCC’s register. Or did I get this wrong?

73 Responses to Are most chiropractors behaving unethically?

  • Our new patient form discuss the VERY RARE possibility that cervical manipulation could lead to permanent injury or risk of death. I believe the likelihood is about as much as being struck by lightning, and far less than dying from taking over-the counter medications, but we still mention it (crazy right?)

    We also explain to all patients that they could try analgesics, NSAIDs, exercise, physio, or osteopathy.

    We document informed consent for every patient both verbally (we write “verbal consent given” and the patient initials next to this), and also their signature is given on the new patient form beneath the above declaration, this is scanned and attached to each patient’s file.

    So the answer is YES. Chiropractor DO follow the guidelines.

    By the way, do you get Neck or Back Pain? judging from images I’ve seen of your posture, I’d guess so.
    Please tell us what you do when you have neck or back pain. This could be an interesting read.

    • ” I believe the likelihood is about as much as being struck by lightning, and far less than dying from taking over-the counter medications, but we still mention it”
      WHAT YOU BELIEVE IS IRRELEVANT – DO YOU HAVE DATA TO SUPPORT YOUR BELIEF?
      “So the answer is YES. Chiropractor DO follow the guidelines.”
      THAT IS ONE CHIRO!
      “what you do when you have neck or back pain”… YOUR DIAGNOSIS FROM A DISTANCE IS AS INCORRECT AS OTHER PARTS OF YOUR COMMENT; I DON’T SUFFER FROM THESE PROBLEMS. IF I DID, I WOULD DO SOME EXERCISES AIMED AT THEM.

      • I didn’t give you a diagnosis. I simply said I wouldn’t be surprised if you had neck or back pain.
        A diagnosis (or clinical impression rather), would require a more detailed case history and thorough examination.
        Let me know if you need any exercises. Chiropractors are fully qualified at exercise prescription and advanced rehabilitation.
        Have a lovely weekend

        • I THINK YOU MIGHT BE WRONG YET AGAIN.
          THIS IS WHAT YOU WROTE ABOUT ME:
          “By the way, do you get Neck or Back Pain? judging from images I’ve seen of your posture, I’d guess so.”
          FUNNY THAT YOU DID NOT FEEL LIKE GOING INTO THE OTHER POINTS I RAISED IN MY ANSWER.

          • No I’m not wrong. What I wrote was as you mentioned above “do you get neck or back pain? judging from images I’ve seen I’d guess so” There is NO diagnosis. Neck pain is not a diagnosis, nor is back pain. They are both symptoms, not conditions such as facet joint syndrome or degenerative disc disease which would both be diagnoses.

            your other points:

            What I believe is irrelevant. I will allow you that point. However the sentence could have been written without “I believe…..”. If we omit these two words, the sentence still makes sense, and is relevant to the point I am making – that the likelihood is extremely rare.

            In fact the likelihood of something sinister happening from chiropractic treatment is apparently even LESS than being struck by lightening according to this article http://www.bbc.co.uk/news/blogs-magazine-monitor-26583325

            As for your other points. I assure you that I represent the vast majority of the profession with regards to obtaining consent. As a chiropractor, I would say that I have much greater insight into the day to day clinical workings of our profession.

            As for these points:

            *this treatment has not been shown to be effective for non-spinal conditions,
            very few chiropractors claim to treat NON-spinal conditions, they are the minority of the profession.

            for back and neck pain, it might help but not better than other conservative therapies,
            This is almost positive Ed! wow you ALMOST said that we CAN indeed help with back and neck pain. GREAT RESULT!

            in about half of all patients, it leads to mild to moderate adverse effects that typically last 2-3 days and are severe enough to interfere with the patient’s quality of life,
            WOW! mild to moderate effects. Such as discomfort, pain, tension. Basically what the patient typically complains of. And they last 2-3 days? I think any rational adult would expect discomfort from treatment which was ACTUALLY doing something. I had my tonsils removed ones, I have the most excruciating pain afterwards and couldn’t eat for a week without immense agony. But the job was done. Now I feel better. the discomfort was necessary for healing.

            in an unknown number of patients, it might lead to severe complications, including stroke and death,
            there are other options for your problem that are more effective and/or less harmful.

            The numbers ARE indeed known. They are about 1 person per 3,000,000

            By all means try exercises, try pain killers, try resting, try ice or heat.

            And then try chiropractic, and finally get rid of your symptoms.

          • 1) correct, pain is always a symptom. but you guessed the nature of the pain, didn’t you?
            2) “In fact the likelihood of something sinister happening from chiropractic treatment is apparently even LESS than being struck by lightening according to this article http://www.bbc.co.uk/news/blogs-magazine-monitor-26583325“. PITY THAT THEY DID NOT TEACH YOU IN CHIRO-SCHOOL WHAT EVIDENCE IS.
            3) “I assure you that I represent the vast majority of the profession… THANKS BUT I PREFER EVIDENCE TO ASSURANCES.
            4) YOUR NEXT POINTS ARE UNRELATED TO THIS DISCUSSION.
            5) “By all means try exercises, try pain killers, try resting, try ice or heat. And then try chiropractic, and finally get rid of your symptoms. ARE YOU DEAF? I HAVE NO SYMPTOMS – -OH YES, YOU LIKE TO TREAT SYMPTON-FREE PEOPLE TOO, DON’T YOU?

          • @Conscientious chiro

            What was the incidence of chiro AEs last year?

    • ” . I believe the likelihood is about as much as being struck by lightning,”

      Irrelevant. In addition to the point Edzard made about your belief, unlike lightning, neck manipulation is a choice. In the normal course of life, it is considerably easier to avoid than is lightning.

      Also, given that there is no mandatory reporting of adverse events for any form of quackery, I’m curious how you think the relevant data csn be obtained.

    • @Conscientious Chiro

      “So the answer is YES. Chiropractor DO follow the guidelines.”
      (Dr. Ernst)”THAT IS ONE CHIRO”

      Don’t you know that Dr. Ernst is allowed to make assumptions/sweeping generalizations about the chiropractic profession and you are not? Personally, I don’t know how he has seen the chart notes and documentation of every chiropractic office. But, if he says that you do not represent the majority of the profession, I am inclined to believe his evidence-based approach.

  • This is, of course, the crux.
    But I dispute implications that if patients are fully informed about chiropractic (or any other CAM) they will not consent.
    Why, even the Minister for Cultue has given consent to receive painful stimuli which I am sure he found most therapeutic.

    The fact is ‘there’s nowt so queer as folk’ and folks are not always rational. So, if they do consent, caveat emptor.

    I accept that is not exactly what Edzard’s post suggested. He is rightly concerned about the stance of the GCC itself and whether they make their own regulations stick.

    I guess what we need is a survey into how many chiro patients do give fully informed consent.
    Many love to be loved – and are prepared to become involved in camistry to achieve that end.
    Risks are relatively low compared to the anxieties of having to face the realities of life.

    ‘Contientious Chiro’ has failed to confirm he advises patients of all Edzards five bullet points.
    The first two are particularly important.

    As in medicine, chiros probably would not be struck off simply for failing to obtain fully informed consent, unless the patient was harmed (they might, just might, receive a warning). Here we enter the realm of metaphysics.
    Which is where chiropractic started.

  • According to the General Chiropractic Council: “When explaining risks, you must provide the patient with clear, *accurate* and up-to-date information about the risks of the proposed treatment”

    Reference

    Bearing in mind that chiropractors have no reliable adverse events reporting systems and that many of them claim that chiropractic neck manipulation can’t cause strokes – ref the (deeply flawed) Cassidy study – what are the accepted risks? What statistics do they use? Because it would appear that there is no reliable risk/benefit profile available for chiropractic manipulative treatment.

    The following is lifted from a previous comment that I made on the subject:

    QUOTE

    …members of the public cannot be fully informed of the risks and the benefits of manipulation.

    The present statutory structures have created tribal practitioner police, which are not orientated towards patient safety, through control, to evaluate what is a safe treatment for manipulation of the spine.

    The statutory regulators, (the General Chiropractic Council, the General Osteopathic Council and the Health Professions Council) have not been obliged through an act of parliament to provide members of the public with the same duty of quality of care that other government healthcare providers have since 1999.

    -snip-

    Patients should be able to ask the risks of a particular treatment and should receive informed answers in terms of statistical probability. The consent process should employ a similar method as used in the New Zealand Manipulative Physiotherapy Association in their pre-screening requirement document for cervical spine management.

    All manipulation professions should cooperate to produce evidence of the benefits of the various modalities of manipulation in order that risk/benefit ratios can be produced.

    Manipulators of all disciplines should reduce the use of force, amplitude and velocity in the case of spinal manipulation to a minimum until evidence is forthcoming in terms of statistical probability of the risk/benefit ratio.

    -snip-

    Members of the public are at risk from the failure to obtain appropriate statistics and regulate the techniques taught and used for manipulating the spine. Because of the lack of statistical information the quantum of risk cannot be estimated and stated.

    Practitioners are at risk because they are not given the appropriate information regarding the risks of manipulation of the spine. There is the legal risk of being sued for negligence in case the risk materialises. Statistical probability is used by the courts to decide liability in cases of material risk. Verbal descriptors use terms such as rare, never, often etc, while statistical probability uses figures in ratio form such as 1 in 500,000 and 1 in 250,000.(5)

    The smoke and mirrors requirement by the statutory regulators for registered practitioners to obtain informed consent also poses a risk to the practitioner that they could be struck off the register for not doing so. At the same time the council members and bureaucratic staff can say in their defence that the practitioner was supposed to inform the patient of the risks and benefits of treatment.

    Members of the public cannot have their questions about risks answered without the appropriate statistics being available to practitioners.

    What is the effect of the General Chiropractic Council discounting the risk of manipulation to zero and the General Osteopathic Council and the Health Professions Council not producing figures of the risk of manipulation?

    If no figures in terms of statistical probabilities are available then the medical standard of Bolam (12) applies*. This means that in a court case the defendant practitioner can rely on his colleagues to testify in his defence regarding the safety of the treatment.

    * a practice accepted as proper by a responsible body of medical men skilled in that particular field (12)

    This nullifies the directive for practitioners to obtain informed consent and makes it impossible for members of the public to become involved in informed consent or give it.

    Refs.
    5) The Health Professions Order 2001. s 3. Made under the Health Act 1999, s60. SI 2002 No. 254. 12th February 2002.
    12) Bolam v Friern HMC [1957] 1 WLR 582. P 587. Per McNair J.

    I think it’s about time the General Chiropractic Council clarified the above, but perhaps they know that if they did, and started to regulate chiropractors properly, there could be a good chance that they’d all be looking at less lucrative livelihoods. For example, it’s interesting to note a revealing comment which was made at an inquest in Canada which involved a chiropractor who had allegedly caused a patient to suffer a stroke through neck manipulation. When pressed as to why he wasn’t telling his patients about the ‘potentially catastrophic injuries and death’ which may result from neck manipulation, he said that if he were to tell patients that “I can kill you”, then “half of them would walk out”.

    Link

    • @Blue Wode

      But it’s even worse than Bolam for chiros, because of Bolitho – a treatment must have a logical basis. [1]

      You said:

      Patients should be able to ask the risks of a particular treatment and should receive informed answers in terms of statistical probability.

      Case law has changed since your comment. After Montgomery v Lanarkshire Health Board in 2015, [2] it is no longer adequate for the chiro just to answer any questions a customer might have; the Supreme Court said:

      81. … the law …, instead of treating patients as placing themselves in the hands of their doctors (and then being prone to sue their doctors in the event of a disappointing outcome), treats them so far as possible as adults who are capable of understanding that medical treatment is uncertain of success and may involve risks, accepting responsibility for the taking of risks affecting their own lives, and living with the consequences of their choices.

      82. In the law of negligence, this approach entails a duty on the part of doctors to take reasonable care to ensure that a patient is aware of material risks of injury that are inherent in treatment. … [there is a] fundamental distinction between, on the one hand, the doctor’s role when considering possible investigatory or treatment options and, on the other, her role in discussing with the patient any recommended treatment and possible alternatives, and the risks of injury which may be involved.

      83. The former role is an exercise of professional skill and judgment: what risks of injury are involved in an operation, for example, is a matter falling within the expertise of members of the medical profession. But it is a non sequitur to conclude that the question whether a risk of injury, or the availability of an alternative form of treatment, ought to be discussed with the patient is also a matter of purely professional judgment. The doctor’s advisory role cannot be regarded as solely an exercise of medical skill without leaving out of account the patient’s entitlement to decide on the risks to her health which she is willing to run (a decision which may be influenced by non-medical considerations). Responsibility for determining the nature and extent of a person’s rights rests with the courts, not with the medical professions.

      Although this refers to doctors, there’s no reas it wouldn’t also apply to other health professionals and chiros. A chiro who doesn’t ensure that their customers are made aware of all the facts – whether the customer asked about it or not – risks falling foul of this, potentially landing themselves in very serious trouble.

      References

      1. Bolitho v. City and Hackney Health Authority [1997] UKHL 46; [1998] AC 232; [1997] 4 All ER 771; [1997] 3 WLR 1151 (13th November, 1997). not found. http://www.bailii.org/uk/cases/UKHL/1997/46.html.

      2. Court TS. Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland) – The Supreme Court. https://www.supremecourt.uk/cases/uksc-2013-0136.html.

  • Informed consent has been a common law requirement for all professions here in Australia since 2000! I have used it as standard since 1995. Its on its 6th revision. Both the registration board and my professional indemnity insurer check that I utilize it every year! Its mandatory! Since 1995 I have only had one patient refuse care after informed consent.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051308/?tool=pmcentrez
    Why has something similar for all professions not been implemented in the UK?

    • I think it has; the better question would then be: WHY DOES THE GCC FIND IT NECESSARY TO REMIND ITS MEMBERS OF SOMETHING SO OBVIOUS?
      could the answer be that chiros ignore the ethical imperative? the survey I cited implies exactly that!

  • This may be seen as a off topic argument, but if we look at malpractice insurance, which I would imagine keeps a pretty tight leash on adverse effects and risks/dangers of each specialty. I am a chiropractor and my malpractice insurance is $2000 a year, starting out it is only $600 for a first year DC. If the commercial risk assessors have a say about the risks of chiropractic care, it seems pretty low to me.
    I am also a chiropractor who uses the informed consent fairly closely as was stated above(I say 1-2 days soreness, and if it is 3+ days they need to let me know). People come to their chiropractor based on a referral from someone who it helped before, good past experiences, or referral from another provider. Either way, most have it in their head that they will do what the doctor/chiro says because they already made up their mind to do it before they came. I have some patients who either I or they decide that SMT isn’t a good option and we do other conservative care options and if results for any patients are as ineffective as it seems has been posted above, then I refer to an orthopedist, PCP, or other.
    To Validate some of Edzards posts, I do adjust a large percentage of patients and some adjustments are on spots that are just lightly tender. I am working to train my patients that not every back pain is “adjustable” but just like I have heard many MDs/DOs/NDs that patients come seeking a pill to take care of their illness, my patients often come to me seeking an adjustment, and if they feel the adjustment will help, then I let them have their placebo effect because that is a larger part of all medicine then any give it credit for. ( I do let them know that the exercises/nutrition/etc.. is the real treatment and that the adjustment may not help and ask them to make the choice.)
    I wish we could see each other as specialized in our own categories. Yes, some chiros are crap for docs… but so are some MD’s, and PT’s, and any other profession.

    • oh the malpractice insurance fallacy! if you are treating serious diseases, insurance is likely to be far higher than for clinicians who predominantly treat back ache. try again, please.

      • In Oregon I treat much more than just back pain. I am licensed as primary care. I am helping patients manage BP, cholesterol, and if I wanted to could specialize in obstetrics, gynaecology, proctology, or perform minor surgery. So yes I can, and am treating serious diseases. You are right I am predominantly treating back ache, but then again being licensed to diagnose and treat even non-msk conditions comes with a decent amount of risk. So in your opinion you can claim insurance fallacy, but as we know wrong opinions don’t hold a candle to facts.

        • And in England, we say WHEN YOU ARE IN A HOLE STOP DIGGING!
          Your reasoning is silly: real doctors do all of what you describe PLUS have to take life/death decisions almost every day.

          • This is my last comment on your blog. There is no discussion with you, when something is contrary to your stereotypes, you jump to another exaggerated thought in your head. Not all Drs. In England make life and death decions every day, this is where you showed a severe break with reality. There is no logical discussion when someone is so broken with the superiority of their statements that they have a infallable God complex. Sir, I bid you a warm and happy life.

          • most real doctors make life and death decisions, perhaps not all every day, but fairly regularly. chiros do this very rarely. the stakes are entirely different, and that’s why your insurance argument is fallacious. if you call this a god-complex, you are just silly.

        • Scott Richman said:

          There is no discussion with you, when something is contrary to your stereotypes, you jump to another exaggerated thought in your head.

          If you had been able to make logical, rational, cogent and coherent points, we could have discussed those.

          • true!
            he first issued an untenable fallacy and then did not like when I disclosed it as fallacious.
            rather typical for some chiros, I find.

        • I just want to note that Scott Richman has been licensed as a chiropractor for less than seven months (Oregon original license date is 5 October 2015) and that the website of the clinic at which he works is saturated with nonsense, including the dreaded “vertebral subluxation complex”.

          • @ Kyle C

            I think it’s worth posting a link to the website:
            http://www.greenwaychiropractic.com/info/subluxations/

          • Wow, you all know how to pull someone back in after they have removed themselves from the conversation.
            First thank you for pointing out the content my website hosting company has on the site.
            On that same note, I would ask that my personal life be respected and left off this site. Please remove the posts and links. I have removed the link from my site to the pre-created subluxation complex page and will be editing the content my website hosting company has placed on my site. I do acknowledge there is alot of crap on the site to be removed/changed please understand it will take time. Thank You

      • Interesting article!
        http://www.medscape.com/viewarticle/737420
        Often when it comes to malpractice suits its about communication and not what was or wasn’t done!

  • Dr. Scott wrote: “First thank you for pointing out the content my website hosting company has on the site.”

    That sounds like an abdication of responsibility to me. Wasn’t it up to you to check the content?

    Dr. Scott wrote: “On that same note, I would ask that my personal life be respected and left off this site.”

    Your website is in the public domain, therefore any details about your personal life have been/are under your control.

    Dr. Scott wrote: “Please remove the posts and links”

    That is entirely at the discretion of Professor Ernst, and I don’t see any good reason why he should.

    Dr. Scott wrote: “I have removed the link from my site to the pre-created subluxation complex page and will be editing the content my website hosting company has placed on my site. I do acknowledge there is alot of crap on the site to be removed/changed please understand it will take time.”

    I suggest that you publish an information note on your Home Page – and in your clinic – which informs your patients that there was “alot of crap” on your website up until today, and include a list of reliable, scientific resources on chiropractic which they can consult in order to become properly informed. To do otherwise would be misleading.

  • “When explaining risks, you must provide the patient with clear, accurate and up-to-date information about the risks of the proposed treatment and the risks of any reasonable alternative options…”

    Do they mean stuff like this re explaining “…risks of any reasonable alternative options”?

    WARNING
    Serious Neurologic Adverse Reactions with Epidural Administration
    Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids (see WARNINGS: Neurologic). Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke. These serious neurologic events have been reported with and without use of fluoroscopy. The safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use.

    http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/AnestheticAndAnalgesicDrugProductsAdvisoryCommittee/UCM422692.pdf

  • EE et al. do you think that all of these poor people had informed consent and informed choice explained to them prior to treatment?

    http://www.cnbc.com/2016/05/04/medical-errors-are-third-leading-cause-of-death-in-united-states-study.html

    • @ GibleyGibley on Wednesday 04 May 2016 at 20:55
      (Dodgy New Zealand chiro who won’t use his/her real name),

      A CNBC “news” report? You are hilarious (but, after all, you are a chiro so anything is as good as evidence for you).

    • @ David re your link above (Medical Error Is Third Leading Cause of Death in US)

      I hope your argument isn’t that people should avoid conventional medicine and resort to quackery instead…

      “The ironic thing is that all the statistics these doctor-bashers have accumulated come from the medical literature that those bashed doctors have written themselves. Scientific medicine constantly criticizes itself and publishes the critiques for all to see. There is NOTHING comparable in the world of alternative medicine.
      When errors are identified, doctors take actions to prevent them. We are constantly trying to reduce the number of medication errors, the number of unnecessary surgeries, the overuse of antibiotics, etc. It’s one thing to say that more efforts are needed. It’s something else to condemn all of modern medicine because we imperfect humans have not managed to entirely eliminate all errors.
      I’ll be the first to admit that there is a great deal wrong with modern medicine, but it makes more sense to fix what is wrong than to reject the whole shebang. Alternative medicine is not a rational alternative; it’s a belief system with a very poor track record.
      If the doctor-bashers want to play statistics, how about comparing death rates with modern scientific medicine to death rates with alternative medicine and death rates with no medicine at all. That might really be interesting!”

      Ref: http://www.sciencebasedmedicine.org/death-by-medicine/

      • Oh the scrambling, spin and name calling. It was only a matter of time before a response like this was posted. Congrats

        I’m surprised it wasn’t “at least these people died in the hands of REAL doctors, instead of suffering alive duped by the quacks”

        • Derry Merbles wrote: “I’m surprised it wasn’t “at least these people died in the hands of REAL doctors, instead of suffering alive duped by the quacks””

          Your surprise reveals much about your standards.

          FYI, some people don’t suffer alive at the hands of quacks. They die.
          http://whatstheharm.net/

          • Your floundering reveals much about your obdurateness

            “FYI, some people don’t suffer alive at the hands of quacks. They die.”
            like 251,454 a year strong?

            That website provides abysmally unchecked and unproved anecdotes. For someone who prides themselves on evidence-based research, you must have felt disgusting posting that link.

          • @ Derry Merbles on Friday 06 May 2016 at 14:18
            (New Zealand chiropractor who will not reveal his identity for fear of showing the nonsense propagated on his website.)

            You love anecdotes except when they show the damage caused by your type of witchcraft.

          • My mistake, the NZ chiro is Gibley, not Derry Merbles, as far as I am aware.

      • @ Blue Wode
        I wasn’t making an argument, merely an observation that I thought might be of interest to those concerned with the best interests of patients and achieving a balanced view.

    • Shame on the authors and publishers of this piece. This is a sensationalized title that harmfully misrepresents data, and seems to propel a dangerous paradigm against the medical establishment.

      Disclosure: I am part of the medical establishment. I am a surgeon, and I acknowledge that this establishment has inherent error, and that error has and will lead to adverse events, including death. This does, and historically has, merited investigation. My protest is the dramatic overrepresentation of this phenomenon to dangerous proportions.

      The claims of this paper are based on studies that have essentially found databases with patients that:

      a. were in a hospital
      b. had an adverse event during their stay
      c. died
      d. had someone indicate that the event was preventable
      e. had someone indicate that the event contributed to the death

      There are several deficiencies in extrapolating this to the “third leading cause of death”.

      1. Contribution is not Causation. A piano that falls on a pedestrian results in a death caused by a falling piano. Although any number of bystanders may have been able to alert the pedestrian or push him out of the way, the bystanders did not cause his death. The inaction of the bystanders may have contributed to his death, but far and away, their inaction was not the cause.

      One common adverse event that leads to death is pneumonia. The overwhelming number of patients with pneumonia do not die, because humans have immune systems that prevent that. Many deaths from pneumonia occur because of an arsenal of comorbidities and failing organ systems that lead to the pneumonia becoming the needle breaking the camel’s back. The author’s cited sources would rule that all deaths from health-care-associated- or ventilator-associated pneumonia are “caused” by medical errors, but that is a reductionist and dangerously erroneous conclusion.

      Cardiovascular disease is the leading cause of death. Most experts would agree that most patients that die of an atherosclerotic coronary event would not have died during that episode if they did not have the systemic, lifelong condition of cardiovascular disease. If you wish to list “medical error” on the list in third place after cardiovascular disease, can you make the same analysis? If you didn’t put the patient on the ventilator, the one that is associated with his pneumonia, which someone thinks contributed to his death, would he have survived that episode? The patient was sick enough that he couldn’t breathe for himself – do we really think that keeping him off the ventilator, or simply keeping his head elevated at 30 degrees or following the “ventilator bundle” would have kept all those patients from dying?

      I contend that it is a profound public health disservice to compare such a cavalier characterization of “medical error” with entities as systemic & chronic as cardiovascular disease and cancer.

      2. Reducible risk is not Preventable. Adverse events must be characterized as “preventable” to be included in the author’s datasets. Deep vein thrombosis (DVT), and subsequently pulmonary embolism, is considered a “preventable” adverse event – and one that leads to death. It is certainly possible to reduce the risk of DVT with medicines and protocols. However, there are multiple, profoundly influential, biologic mechanisms that cause DVT, which are out of our control. Fundamentally, the body is designed to figure out when and how to make clots, and our lives depend on its ability to do so. For the foreseeable future, modern medicine will not be able to precisely determine when and where to make and prevent clots in the body. To believe that health care providers can prevent all DVTs from forming is to profoundly misunderstand pathophysiology. To further believe that all deaths due to DVTs are therefore preventable, is to misunderstand both pathophysiology and logic.

      3. We accept that intervention has risk. All intervention has risk, and we as a society, as patients, and as providers, accept that. The case example, a pericardiocentesis, cannot be performed without risk. For the foreseeable future, there will never exist a way to transport fluid from the pericardial sac (point A) to the outside world (point B) without disturbing the matter between points A & B. It is tragic that this case resulted in the disruption of her liver and her subsequent death. However, it is naive to believe that there exists a human being who can put a needle into someone’s heart consistently without ever having an adverse event – this is an inherent risk of the procedure. Society accepts that they have informed consent on these risks after consultation with their providers, and that they have the autonomy to take on these risks with the potential of the attendant benefits.

      4. Fearmongering creates risk. The authors and publishers of this piece may simply wish to cast a light in a field of sizable consequence that lacks concrete data. That aim is admirable. What I protest, however, is the hyperbole that they have resorted to in order to achieve that aim. That hyperbole carries its own risk.

      The case example cites “unnecessary” tests as an root cause of the patient’s death. We know that a significant contributor to unnecessary testing is “defensive medicine”. Defensive medicine draws its origins from malpractice claims, both reasonable and baseless, which has led to actual changes in practice. One notable change is the increase in unnecessary tests that providers order to protect themselves from potential litigation.

      It is not a stretch to see the author’s proposed paradigm pushing physicians into inaction – for fear of retribution upon medical errors caused by preventable adverse events. For the case example, a pericardiocentesis – if this is to be the cornerstone case of the movement, would we not expect this procedure to be performed less often? There is a tangible risk to this modification – the procedure does enable detection of life-threatening conditions, among other things.

      This piece is a sensationalized sound bite based on misrepresented data that is both inaccurate in its implications and harmful to public welfare.”

      Benjamin Wei MD

      • @Doc Dale

        “Fearmongering creates risk. The authors and publishers of this piece may simply wish to cast a light in a field of sizable consequence that lacks concrete data. That aim is admirable. What I protest, however, is the hyperbole that they have resorted to in order to achieve that aim. That hyperbole carries its own risk.”

        “This piece is a sensationalized sound bite based on misrepresented data that is both inaccurate in its implications and harmful to public welfare.”

        Welcome to the world of Edzard Ernst and his disciples, their raison d’etre is exactly as you describe, but for the world of ‘alternative medicine’.

        Incidentally, all the chiropractors I know and work with follow sound protocols in their management of neuromusculoskeletal disorders, inline with the current and proposed NICE guidelines for the management of low back pain. Currently there are no guidelines for the management of the vast majority of other disorders that responsible chiropractors dedicate their working lives to helping patients with. However, you can rest assured that future knowledge about the benefits and risks of various interventions will shape their approach just as it does in other areas of responsible healthcare.

        • @ David on Monday 09 May 2016 at 01:27

          “you can rest assured that future knowledge about the benefits and risks of various interventions will shape their approach just as it does in other areas of responsible healthcare.”

          In that case, why are you treating anyone when there is nothing in Cochrane to support it?

  • There are two serious issues facing health care in the world.
    1) Opiod abuse and the record numbers of deaths in the U.S.A. as a direct result of this.
    2) Antibiotic over-use for conditions that they are not required. E.g. common cold etc.

    Both these issues are driven by the medical establishment and part of the problem is the establishments reluctance to do anything about it.
    “Medicine” i.e. Prof Ernst, Blue Wode, should get its own house in order before looking at other healthcare providers.

    As an aside, any registered and qualified health care profession could be included under the title “medical error”, not just medical practitioners. I believe that this issue applies as much to physiotherapists, nurses, chiropractors, osteopaths etc. as it does to medical practitioners.

    • GibleyGibley wrote: ” “Medicine” i.e. Prof Ernst, Blue Wode, should get its own house in order before looking at other healthcare providers.”

      @GibleyGibley

      Are you being serious? You think that conventional medicine should get its house in order before anyone can demand that alternative medicine does? You think that it’s not acceptable to point out that chiropractic spinal manipulation carries an unfavourable risk/benefit profile – that it can maim and kill?

      In other words, you’re happy for this to continue…

      Quote
      “Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”

      Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009).
      Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.

      Also see http://www.ebm-first.com/chiropractic/risks.html and http://whatstheharm.net/

      I really don’t understand your logic.

      • I really don’t understand your logic.
        POSSIBLY BECAUSE IT IS NO LOGIC?

      • Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.

        From the report, it also states that the results of the study “… do not necessarily suggest that inappropriate care is being rendered. That the case may be in practice, manipulation or mobilization is used for highly appropriate indications” (page 43).

      • “You think that it’s not acceptable to point out that chiropractic spinal manipulation carries an unfavourable risk/benefit profile – that it can maim and kill?”

        Would this also hold true regardless of which profession delivered the spinal manipuation?

        • Yes. Now please answer the question that I asked *you* directly.

          • Your question cannot be answered based upon the information you provided. One would have to critically evaluate the evidence of both risks and benefits (as well as the evidence from which it was derived) as well as compare those findings with the benefits and risks of other alternatives for the condition/s. I’m not being obtuse but you present this as if it’s black and white and such topics are rarely B&W.

  • Doc Dale wrote: “From the report, it also states that the results of the study “… do not necessarily suggest that inappropriate care is being rendered. That the case may be in practice, manipulation or mobilization is used for highly appropriate indications” (page 43).”

    @ Doc Dale

    It is more than likely that the administration of inappropriate care is the rule rather than the exception.

    Bearing in mind that the findings of robust systematic reviews show that neck manipulation is *not superior* to other treatments in effectiveness, and that mobilisation has been shown by a Cochrane systematic review to be equally effective, your quote above doesn’t seem to stand up to scrutiny – i.e. the available data on chiropractic practices show that the majority of chiropractors don’t adopt an approach that is based on science.

    For example, a recent study by McGregor et al, which many chiropractors claimed showed that only 18% of chiropractors delivered inappropriate treatment…

    Ref: http://bmccomplementalternmed.biomedcentral.com/articles/10.1186/1472-6882-14-51

    …turned out not to be the good news that chiropractors had hoped for. Significantly, the study stated: “As with any investigation, this study has limitations. First, although the response rate was good at 68%, it remains unclear what practice perspectives and behaviours are associated with non-participants. Also, although the sample was randomly selected and stratified according to the number of licensed practitioners in each province, the sample represented only approximately 12 percent of practitioners from each province. As always, there is the possibility that despite the randomization scheme, a unique sample was selected, and generalizability is a possible concern.”

    Certainly, the results were somewhat inconsistent with other available data:
    http://tinyurl.com/pts2ns5

    Indeed, McGregor’s 1st, 3rd, 4th, 5th, and 6th subgroup descriptions don’t seem to exclude the unethical chiropractor element. IOW, 5 of the 6 subgroups could easily indulge in chiroquackery – (1) “Wellness”, (3) “general probs”, (4) “organic-visceral”, and (5/6) “subluxations”.

    Also, according to Science Based Medicine author, Jann Bellamy: “The survey was of Canadian chiropractors, most of whom graduated from Canadian Memorial Chiropractic College, which appears to have a more orthodox orientation than, for example, Life or Palmer…the groups not included in the unorthodox category doesn’t mean the others are necessarily free of unorthodox views.”

    As for the recent Chiropractic Observation and Analysis Study (COAST) which claimed to provide “an understanding of current chiropractic practice”, Harriet Hall (MD) at Science Based Medicine, who authored the post in the following link, has pointed out that the study…

    QUOTE
    “…tells us that a substantial number of chiropractors use quack methods, and the ones who do obviously can’t be science-based. It tells us that children are being treated with chiropractic in the absence of any evidence that it is effective…The study leaves many questions unanswered and raises some new ones; and it doesn’t provide any evidence to support the claims that chiropractic is being “reformed”.”

    Link: http://www.sciencebasedmedicine.org/chiropractic-reform-myth-or-reality/

    Doc Dale, as I always ask when I post such links, do you have any better data?

    • Based upon your approach and references, the best one could state is that around 18% of chiropractors consistently use SMT inappropriately. I can accept that percentage.

      • @ Doc Dale

        1:5 *consistently* using SMT inappropriately amounts to millions of chiropractic customers being put at risk of being maimed or killed. How could that ever be acceptable?

        Further, I think I’ve demonstrated that the *inconsistent* inappropriate use of SMT could be pretty high – i.e. it’s more than likely that many more millions are being put at risk of having their lives wrecked.

        • One would have to clearly define which ones one considers “inappropriate” (and why) and then show which inappropriate uses do indeed increase risk of being “maimed or killed”. One may consider SMT inappropriate based upon their philosophical views (as pointed out above) but that does not necessarily mean their clinical application of SMT as applied increases the risk of being “maimed or killed”. In some cases yes (SMT to cure cancer) but in some cases perhaps not (SMT to restore vitality).

          • IMO, in view of this http://edzardernst.com/2015/08/chiropractic-spinal-manipulation-placebo/ the Precautionary Principle should apply https://en.wikipedia.org/wiki/Precautionary_principle . Additionally, chiropractors should be setting up adverse event reporting systems. However, most don’t seem to care about either.

          • Inspite of the errors Ernst made in his commentary, if I recall in this study around only 25% of the subjects received SMT. The rest received mobilization and flexion/distraction. Also, I recall that the authors pointed out that chiropractors utilize a multimodal approach in clinical practice; however, this study only pulled out one (really three) approaches. I don’t recall if they did a post hoc on each approach. Also, if I recall, this study had instructed both groups on stretching and strengthening exercise but didn’t followup if both groups utilized equally (they may have, I’d have to find it and read it again). Since we know that exercise can have a positive effect on chronic low back pain it is an important variable. Inotherwords, does this study really represent how most chiropractors approach chronic low back pain in a geriatric population, or does it, like a lot of “chiropractic” research, just pull out the one modality thus perhaps limiting the studies application?

            I know that England has set up a database for DCs to report adverse events. Last I saw they opened up the database to a couple of other European countries and plan to expand as resources allow. Also, I believe that Palmer college has initiated the process of setting up an AE database (could be a different US college). Also, I’ve been told that this is also being set up in Canada. I’ve been advocating for an AE reporting system for years.

  • Derry Merbles wrote: “That website provides abysmally unchecked and unproved anecdotes.”

    Then please provide links to the adverse event reporting systems that have been set up by alternative medicine proponents.

  • Doc Dale wrote: “I know that England has set up a database for DCs to report adverse events. Last I saw they opened up the database to a couple of other European countries and plan to expand as resources allow. Also, I believe that Palmer college has initiated the process of setting up an AE database (could be a different US college). Also, I’ve been told that this is also being set up in Canada. I’ve been advocating for an AE reporting system for years.”

    The adverse events reporting system in England…

    http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1888-british-chiropractic-association-members-attitudes-towards-the-chiropractic-reporting-and-learning-system-a-qualitative-study.html

    …is worse than useless. As Professor Ernst wrote previously on this blog “it gives a veneer of respectability, a notion of safety, while providing neither of these two qualities”.

    • damned if you do, damned if you don’t.

      • please explain

        • Doesn’t matter. In my twenty plus years of discussions with chiro skeptics I’ve only come across one that I consider truly objective in his analysis. It appears no one here has reached that level. I’ll continue my search for such people elsewhere.

          • I am so glad I found someone who claims to be able to judge who is and who isn’t objective.
            my congratulations!

          • It’s not that hard to determine if someone is honestly striving to be objective.

          • @ Doc Dale on Tuesday 10 May 2016 at 13:03

            “Doc” Dale has cracked the poos and stomped off in a huff, so I will translate his post;

            “Doesn’t matter.”
            It does matter but I’ve cracked the poos.

            ” In my twenty plus years of discussions with chiro skeptics I’ve only come across one that I consider truly objective in his analysis.”

            I’ve only ever found one sceptic to agree with me so he, by my definition, is objective. I managed to convince him of the efficacy of chiro despite the lack of evidence in Cochrane.

            “It appears no one here has reached that level.”

            I can’t convince anyone on this blog so they are, again by my definition, not objective. They have not reached “that level” which is to be swayed by my dazzling intellect, solid evidence, and robust discussion.

            “I’ll continue my search for such people elsewhere.”

            I’ll sook off and try to find gullible people elsewhere.

            Dale, are you familiar with the crass expression; “put a broom up and sweep the floor on the way out”.

          • @ Frank, you were wrong on all points.

          • @Doc Dale on Wednesday 11 May 2016 at 13:46

            “@ Frank, you were wrong on all points.”

            You would say that because, as a chiro, you can make any claim, devoid of any evidence.

          • But I don’t.

          • @ Doc Dale on Thursday 12 May 2016 at 12:48

            I wrote;
            “You would say that because, as a chiro, you can make any claim, devoid of any evidence.”

            You wrote;
            “But I don’t.”

            Do you not see the irony? (For rational people, this would not be necessary………………………..)

  • We have had this conversation before on this topic Blue! See this article from 2 years ago in Australia:
    https://www.mja.com.au/insight/2014/7/support-chiropractor-reporting
    I followed up on this article not long ago with a senior medical specialist to find out how the AE reporting system had progressed? He replied that there was “snivelling” from the hospitals on who would pay for it and it went no further!
    A reliable and accurate adverse event reporting system is required for all professions Chiro, ostoe, physio, GP’s in private practice etc!
    A recent paper by Neurosurgeons who did a systematic review and meta analysis of case reports on chiropractic adverse events:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4794386/
    The neurosurgeons commented on the poor quality and high risk of bias in the reports. Thats medical bias and not chiropractic bias!
    If a chiropractor wrote an article with this title “Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation” what would be the reaction here? Also what would be the reaction to this statement if it was made by a chiropractor “In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical dogma.” ??
    I fully support an Adverse Event reporting system that improves accurace, quality and eliminates medical “bias” and “dogma”!

    • @ Critical_Chiro

      Re your support of a Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation, a couple of medical doctors have already torn that paper to shreds. Here are their conclusions:

      Harriet Hall, MD
      “I ask you to imagine that there is a pharmaceutical drug that fits this description. Imagine that there are the same numbers of studies showing an association of that drug with a deadly side effect like stroke or death. The FDA would pull it off the market; they wouldn’t wait for definite evidence of causation that fulfilled all of Hill’s criteria. And I think the people who are making excuses for neck manipulation would want them to take that drug off the market. I don’t think they would want to take such a drug.”
      https://www.sciencebasedmedicine.org/chiropractic-and-stroke-no-evidence-for-causation-but-still-reason-for-concern/

      Mark Crislip, MD:
      “If chiropractic neck manipulation were a medication? Based on the severity of the potential reaction it would have a black box warning in the PDR. If side effects were combined with efficacy, chiropractic would never be approved, much less make it out of clinical trials.”
      https://www.sciencebasedmedicine.org/chiropractic-ignoring-the-precautionary-principle-since-1895/

      • BW, if the best you can do is quote the ardent propagandist, Harriett Hall and her blogger side kick Mark Crislip, then you have scored an “own goal”. Please do better than this to be taken seriously.

        • @ GibleyGibley

          Why not challenge their arguments in the comments here? Or are you no match for their critical thinking skills?

          My money’s on the latter.

        • @ GibleyGibley on Tuesday 10 May 2016 at 21:28
          (A New Zealand chiro who won’t reveal his/her identity for fear of exposing the nonsense s/he engages in)

          Quote;
          “Blue Wode on Wednesday 11 May 2016 at 08:25
          @ GibleyGibley

          Why not challenge their arguments in the comments here? Or are you no match for their critical thinking skills?

          My money’s on the latter.”

          So is mine and safe as houses too.

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