Chiropractors like to promote themselves as primary healthcare professionals. But are they? A recent survey might go some way towards addressing this question. It was based on a cross sectional online questionnaire distributed to 4 UK chiropractic associations. The responses were collected over a period of two months from March 26th 2012 to May 25th 2012.
Of the 2,448 members in the 4 participating associations, 509 chiropractors (~21%) completed the survey. The results of the survey show that the great majority of UK chiropractors surveyed reported evaluating and monitoring patients in regards to posture (97.1%), inactivity/overactivity (90.8%) and movement patterns (88.6%). Slightly fewer provided this type of care for psychosocial stress (82.3%), nutrition (74.1%) and disturbed sleep (72.9%). Still fewer did so for smoking (60.7%) and over-consumption of alcohol (56.4%). Verbal advice given by the chiropractor was reported as the most successful resource to encourage positive lifestyle changes as reported by 68.8% of respondents. Goal-setting was utilised by 70.7% to 80.4% of respondents concerning physical fitness issues. For all other lifestyle issues, goal-setting was used by approximately two-fifths (41.7%) or less. For smoking and over-consumption of alcohol, a mere one-fifth (20.0% and 20.6% respectively) of the responding chiropractors set goals.
The authors of this survey concluded that UK chiropractors are participating in promoting positive lifestyle changes in areas common to preventative healthcare and health promotion areas; however, more can be done, particularly in the areas of smoking and over-consumption of alcohol. In addition, goal-setting to support patient-provider relationships should be more widespread, potentially increasing the utility of such valuable advice and resources.
When I saw that a new UK-wide survey of chiropractic has become available, I had great expectations. Sadly, they were harshly disappointed. I had hoped that, after going to the considerable trouble of setting up a nationwide survey of this nature, we would have some answers to the most urgent questions that currently plague chiropractic and are amenable to study by survey. In my view, some of these questions include:
- How many chiropractors actually see themselves as primary care professionals?
- What conditions do chiropractors treat?
- Specifically how many of them believe they can treat non-spinal conditions effectively?
- How many chiropractors regularly treat children?
- For which conditions?
- How many patients get X-rayed by chiropractors?
- How many are in favour of vaccinations?
- How many are aware of adverse effects of spinal manipulation?
- How chiropractors obtain informed consent before starting treatment?
- What percentage of chiropractors use spinal manipulation?
- What other treatments are used how often?
- How often do chiropractors advise their patients about medications prescribed by real doctors?
- How often do they refer patients to other health care providers?
All of these questions are highly relevant and none of them has recently been studied. But, sadly, the new paper does not answer them. Why? As I see it, there are several possibilities:
- Chiropractors do not find these questions as relevant as I do.
- They do not want to know the answers.
- They do not like to research issues that might shine a bad light on them.
- They view research mostly as a promotional exercise.
- They did research (some of) these questions but do not dare to publish the results.
- They will publish the results in a separate paper.
It would be interesting to hear from the authors which possibility applies.
Recently I came across an interesting speech on alternative medicine which impressed me for a number of reasons. It made me think of a little game: the first person who correctly guesses who its author is, and posts the right answer as a comment on this blog, will receive a free copy of my new book A SCIENTIST IN WONDERLAND.
Here are 2 paragraphs from the speech in question:
It is known that not just novel therapies but also traditional ones, such as homeopathy, suffer opposition and rejection by some doctors without having ever been subjected to serious tests. The doctor is in charge of medical treatment; he is thus responsible foremost for making sure all knowledge and all methods are employed for the benefit of public health…I ask the medical profession to consider even previously excluded therapies with an open mind. It is necessary that an unbiased evaluation takes place, not just of the theories but also of the clinical effectiveness of alternative medicine.
More often than once has science, when it relied on theory alone, arrived at verdicts which later had to be overturned – frequently this occurred only after long periods of time, after progress had been hindered and most acclaimed pioneers had suffered serious injustice. I do not need to remind you of the doctor who, more than 100 years ago, in fighting puerperal fever, discovered sepsis and asepsis but was laughed at and ousted by his colleagues throughout his lifetime. Yet nobody would today deny that this knowledge is most relevant to medicine and that it belongs to the basis of medicine. Insightful doctors, some of whom famous, have, during the recent years, spoken openly about the crisis in medicine and the dead end that health care has maneuvered itself into. It seems obvious that the solution is going in directions which embrace nature. Hardly any other form of science is so tightly bound to nature as is the science occupied with healing living creatures. The demand for holism is getting stronger and stronger, a general demand which has already been fruitful on the political level. For medicine, the challenge is to treat more than previously by influencing the whole organism when we aim to heal a diseased organ.
Guest post by Dr. Richard Rawlins MB BS MBA FRCS, Consultant Orthopaedic and Trauma Surgeon
On 14th November 2013 the Daily Telegraph advised that ‘Meditation could help troops overcome the trauma of war: Troops suffering post traumatic stress should take up yoga and acupuncture to get over the horrors of war. The Royal Navy and Royal Marines Children’s Fund is urging troops to try alternative therapies to get over psychological disorders when they return from conflict zones. After receiving a Whitehall grant, the charity has written a book aimed at helping families understand and cope with the impact and stresses suffered by troops before, during and after warfare. It suggests servicemen try treatments such as massage, reflexology, reiki and meditation.’
As a former Surgeon Lieutenant Commander in the Royal Naval Reserve I treated servicemen on their return from the Falklands. As a father of a platoon commander who served with the Grenadier Guards in Helmand I support Combat Stress. As a member of the Magic Circle I am well acquainted with methods of deceit, deception and delusion. As a doctor I care and hope to see all patients treated appropriately, but alternative therapies must be considered critically.
To assist management of Post Traumatic Stress Disorder the Children’s Fund book provides details of relevant therapies, institutions providing them and knitting patterns for making dolls representing the service personnel and their families. The title Knit the Family is both a suggestion for practical help by making dolls and a metaphor for knitting families back together after deployment. All of which is highly laudable and deserving of substantial support. But…
I do not doubt yoga, meditation, relaxation and doll making can provide valuable emotional support for one of the most pernicious outcomes of combat. I do not doubt that support from an empathic caring practitioner or a conscientious counsellor is of benefit. But what is the added value of pressing on ‘zones’ in the feet? Of positioning hands around a patient and providing them with charms? Of feeling for and adjusting ‘subtle rhythms in cerebro-spinal fluid’? Of inserting needles in the skin? Unless there is evidence that such manoeuvres and modalities actually do provide benefit greater than any other method for producing placebo effects – why spend any valuable funds on such practices? Would not the charitable funds be better spent on psychotherapy, counselling, yoga and meditation? There is no need for CAM therapy. The RN & RM Children’s Fund suggests that complementary and alternative medicine can help PTSD. I know of no evidence alternatives such as reiki, reflexology, CST, acupuncture, Emotional Freedom Techniques (utilising ‘finger tapping’), Thought Field Therapy and Somatic Experiencing all of which are set out in the charity’s book, can provide any benefit. Indeed, the book admits there is no scientific evidence of such benefit. Spending time in a therapeutic relationship helps, but there is no evidence the therapies have any effect on their own account – and there is plenty of evidence they almost certainly do not. That is why they are referred to as being implausible and are termed ‘alternative medicine’.
In order service personnel and their families can give fully informed consent to any proposed treatment they will need to consider the probability that they are wasting time and scarce funds on implausible treatments. And members of the public who might wish to support the charity will need to carefully consider the use to which their funds might be put.
The National Institute for Clinical Excellence (NICE) has Guidelines for the management of Post Traumatic Stress Disorder and emphasises ‘Families and carers have a central role in supporting people with PTSD and many families may also need support for themselves …Healthcare professionals should identify the need for appropriate information about the range of emotional responses that may develop and provide practical advice on how to access appropriate services for these problems.’
Note that the NICE guidelines, quoted in Knit the Family, require that PTSD support services should be ‘appropriate’. So presumably the Fund has decided that implausible non-evidenced based modalities of treatment are appropriate. But just how did it come to such a decision? I have asked questions on this and a number of other points and await an answer.
And there is more to this matter. Knit the Family acknowledges the support it has received from Whitehall’s Army Covenant Libor Fund and also from the Barcarpel Foundation. Barcarpel’s website tells us it ‘is a particularly enthusiastic supporter of Complementary Medicine’ and ‘has made substantial donations to the Homeopathic Trust for Research & Education as well as establishing the Nelson Barcapel Teaching Fellowship at Exeter, specifically to enable medical practitioners to take the Integrated Healthcare programme.’ ‘Nelson’ not for the Admiral but for the firm which manufactures homeopathic remedies, sponsored the inaugural meeting of the ‘College of Medicine’, and whose Chairman Robert Wilson is also Chairman of Barcarpel. And ‘integrated medicine’ means the incorporation of non-evidenced based therapies with orthodox care. Which might be reasonable if there was evidence CAMs had an effect on PTSD – but there is no such evidence.
‘Special thanks are given to Jonathan Poston, Chair of the Craniosacral Therapy Association, for assistance with setting up the project; Liz Kalinowska, Fellow of the Craniosacral Therapy Association, for wise advice; Michael Kern, Founder/Principal of Craniosacral Therapy Educational Trust; Cathy Cremer, whose experience with the UK Forces Project has contributed to an understanding of how best to explain the benefits of CST for those suffering from PTSD; Silvana Calzavara whose experience working at Headway East London (acquired brain injury) proved invaluable at the Portsmouth CST clinic; Monica Tomkins, Eva Kretchmar, Sally Christian, Talita Harrison, Cathy Brooks and Simon Copp for their contribution in carrying the CST project forward.’
So we see that a group of enthusiasts for CST have inveigled their way into the Children’s Fund and are set on promoting the use of this implausible therapy for some of our most vulnerable patients. An insurgency if ever there was one. They have not been able to offer any evidence that ‘subtle rhythms’ can be felt in the cerebro-spinal fluid, let alone manipulative methods can influence the flow of cerebro-spinal fluid. And if they are not doing that, they are not doing CST. The care and attention provided by these practitioners can be applauded, but not the methods they purport to use. In which case, why use them? Would the Children’s Fund not do better to spend its funds on plausible evidence based therapies? How has the Fund assessed whether or not the promoters of CST and other CAMs are quacks? Or whether or not they are frauds? The public who are considering donations need to be reassured. The service personnel who so deservedly need support should be treated with honestly, integrity and probity – not metaphysics.
Two of the top US general medical journals have just published articles which somehow smell of the promotion of quackery. A relatively long comment on alternative medicine, entitled THE FUTURE OF INTEGRATIVE MEDICINE appeared in THE AMERICAN JOURNAL OF MEDICINE and another one entitled PERSPECTIVES ON COMPLEMENTARY AND ALTERNATIVE MEDICINE RESEARCH in THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. As this sort of thing does not happen that often, it is perhaps worth having a closer look at these publications. The JAMA-article has already been analysed skilfully by Orac, so I will not criticise it further. In the following text, the passages which are in italics are direct quotes from the AJM-article, while the interceptions in normal print are my comments on it.
…a field of unconventional medicine has evolved that has been known by a progression of names: holistic medicine, complementary and alternative medicine, and now integrative medicine. These are NOT synonyms, and there are many more names which have been forgotten, e.g. fringe, unorthodox, natural medicine It is hoped that the perspectives offered by integrative medicine will eventually transform mainstream medicine by improving patient outcomes, reducing costs, improving safety, and increasing patient satisfaction. Am I the only one to feel this sentence is a platitude?
Integrative medicine has been defined as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.” There is, in fact, no accepted definition; the most remarkable bit in this one is perhaps the term “informed by evidence” which, as we will see shortly, is by no means the same as “evidence-based”, the accepted term and principle in medicine.
The most obvious differences between integrative and conventional medicine are its practitioners, who offer longer consultations and emphasize minimally invasive therapies, such as mind-body approaches, nutrition, prevention, and lifestyle changes, and focus on healing and wellness. Come again! Is that supposed to mean that conventional doctors do not employ “minimally invasive therapies or prevention or nutrition etc.”? In addition to conventional therapies, they may recommend alternatives, such as acupuncture, dietary supplements, and botanicals. BINGO! The difference between integrative and conventional physicians is quite simply that the former put an emphasis on unproven treatments; evidence my foot! This is just quackery by a different name. The doctor-patient relationship emphasizes joint decision-making by the patient and the physician. Yes, that may be true, but it does so in any type of good health care. To imply that the doctor-patient relationship and joint decision-making is an invention of integrative medicine is utter nonsense.
More and more patients seek integrative medicine practitioners. By 2007, approximately 40% of adult Americans and 12% of children were using some form of alternative therapies compared with 33% in 1991.
The number of US hospitals offering integrative therapies, such as acupuncture, massage therapy, therapeutic touch, and guided imagery, has increased from 8% in 1998 to 42% in 2010.Many academic cancer centers offer these integrative practices as part of a full spectrum of care. Other hospitals offer programs in integrative women’s health, cardiology, and pain management. But why? I think the authors forgot to mention that the main reason here is to make money.
Despite the increasing number of patients seeking alternative therapies, until recently, many of these skills were not routinely offered in medical schools or graduate medical education. Yet they are critical competencies and essential to stemming the tide of chronic diseases threatening to overwhelm both our health care and our financial systems. Essential? Really? Most alternative therapies are, in fact, unproven or disproven! Further, conventional medical journals rarely contained articles about alternative therapies until 1998 when the Journal of the American Medical Association and its affiliated journals published more than 60 articles on the theme of complementary and alternative medicine.
The National Institutes of Health established an office in 1994 and a National Center for Complementary and Alternative Medicine in 1998. Because many alternative therapies date back thousands of years, their efficacy has not been tested in randomized clinical trials. The reasons for the lack of research may be complex but they have very little to do with the long history of the modalities in question. The National Center for Complementary and Alternative Medicine provides the funds to conduct appropriate trials of these therapies. The NCCAM- funded studies have been criticised over and over again and most scientists find them not at all “appropriate”. They also have funded education research and programs in both conventional medical nursing schools and complementary and alternative medicine professional schools. Outcomes of these studies are being published in the conventional medical literature. Not exactly true! Much of it is published in journals of alternative medicine. Also, the authors forgot to mention that none of the studies of NCCAM have ever convincingly shown an alternative treatment to work.
Integrative medicine began to have an impact on medical education when 8 medical school deans met in 1999 to discuss complementary and alternative medicine. This meeting led to the establishment of the Consortium of Academic Health Centers for Integrative Medicine, composed initially of 11 academic centers. By 2012, this group had grown to 54 medical and health profession schools in the United States, Canada, and Mexico that have established integrative medicine programs. The consortium’s first international research conference on integrative medicine was held in 2006, with subsequent research conferences being held in 2009 and 2012. Three conferences? Big deal! I have hosted 14 research conferences in Exeter in as many years. I think, the authors are here blowing up a mouse to look like an elephant.
Multiple academic integrative medicine programs across the country have been supported by National Institutes of Health funding and private contributions, including the Bravewell Collaborative that was founded in 2002 by a group of philanthropists. The goal of the Bravewell Collaborative is “to transform the culture of healthcare by advancing the adoption of Integrative Medicine.” It foremost was an organisation of apologists of alternative medicine and quackery. A high water mark also occurred in 2009 when the Institute of Medicine held a Summit on Integrative Medicine led by Dr Ralph Snyderman.
There is clear evidence that integrative medicine is becoming part of current mainstream medicine. Really? I would like to see it. Increasing numbers of fellowships in integrative medicine are being offered in our academic health centers. In 2013, there are fellowships in integrative medicine in 13 medical schools. In 2000, the University of Arizona established a 1000-hour online fellowship that has been completed by more than 1000 physicians, nurse practitioners, and physician assistants. This online fellowship makes it possible for fellows to continue their clinical practice during their fellowship. I see, this is supposed to be the evidence?
A 200-hour curriculum for Integrative Medicine in Residency has been developed and is now in place in 30 family practice and 2 internal medicine residencies. The curriculum includes many of the topics that are not covered in the medical school curriculum, such as nutrition, mind–body therapies, nutritional and botanical supplements, alternative therapies (eg, acupuncture, massage, and chiropractic), and lifestyle medicine. It is not true that conventional medical schools do not teach about nutrition, psychology etc. Not all might, however, teach overt quackery. A similar curriculum for pediatric residencies is being developed. The eventual goal is to include integrative medicine skills and competencies in all residency programs.
Integrative medicine now has a broad presence in medical education, having evolved because of public demand, student and resident interest, increased research, institutional support, and novel educational programs. Now on the horizon is a more pluralistic, pragmatic approach to medicine that is patient-centered, that offers the broadest range of potential therapies, and that advocates not only the holistic treatment of disease but also prevention, health, and wellness.
Is it not an insult to conventional medicine to imply it is not pluralistic, pragmatic, patient-centred, that it does not offer a broad range of therapies, holism and prevention? This article displays much of what is wrong with the mind-set of the apologists of alternative medicine. The more I think about it, the more I feel that it is a bonanza of fallacies, follies and attempts to white-wash quackery. But I would be interested in how my readers see it.
There are few subjects in the area of alternative medicine which are more deceptive than the now fashionable topic of “integrated medicine” (or integrative medicine, healthcare etc.). According to its proponents, integrated medicine (IM) is based mainly on two concepts. The first is that of “whole person care”, and the second is often called “the best of both worlds”. Attractive concepts, one might think – why then do I find IM superfluous, deeply misguided and plainly wrong?
Whole patient care or holism
Integrated healthcare practitioners, we are being told, do not just treat the physical complaints of a patient but look after the whole individual: body, mind and soul. On the surface, this approach seems most laudable. Yet a closer look reveals major problems.
The truth is that all good medicine is, was, and always will be holistic: today’s GPs, for instance, should care for their patients as whole individuals dealing the best they can with physical problems as well as social and spiritual issues. I said “should” because many doctors seem to neglect the holistic aspect of care. If that is so, they are, by definition, not good doctors. And, if the deficit is wide-spread, we should reform conventional healthcare. But delegating holism to IM-practitioners would be tantamount to abandoning an essential element of good healthcare; it would be a serious disservice to today’s patients and a detriment to the healthcare of tomorrow.
It follows that the promotion of IM under the banner of holism is utter nonsense. Either it is superfluous because it misleads patients into believing holism is an exclusive feature of IM, while, in fact, it is a hallmark of any good healthcare. Or, if holism is neglected or absent in a particular branch of conventional medicine, it detracts us from the important task to remedy this deficit. We simply must not allow a core value of medicine to be highjacked.
The best of both worlds
The second concept of IM is often described as “the best of both worlds”. Proponents of IM claim to use the “best” of the world of alternative medicine and combine it with the “best” of conventional healthcare. Again, this concept looks commendable at first glance but, at closer inspection, serious doubts emerge.
They hinge, in my view, on the use of the term “best”. We have to ask, what does “best” stand for in the context of healthcare? Surely it cannot mean the most popular or fashionable – and certainly “best” is not by decree of HRH Prince Charles. Best can only signify “the most effective” or more precisely “being associated with the most convincingly positive risk/benefit balance”.
If we understand “the best of both worlds” in this way, the concept becomes synonymous with the concept of evidence-based medicine (EBM) which represents the currently accepted thinking in healthcare. According to the principles of EBM, treatments must be shown to be safe as well as effective. When treating their patients, doctors should, according to EBM-principles, combine the best external evidence with their own experience as well as with the preferences of their patients.
If “the best of both worlds” is synonymous with EBM, we clearly don’t need this confusing duplicity of concepts in the first place; it would only distract from the auspicious efforts of EBM to continuously improve healthcare. In other words, the second axiom of IM is as nonsensical as the first.
The practice of integrated medicine
So, on the basis of these somewhat theoretical considerations, IM is a superfluous, misleading and counterproductive distraction. But the most powerful argument against IM is really an entirely practical one: namely the nonsensical, bogus and dangerous things that are happening every day in its name and under its banner.
If we look around us, go on the internet, read the relevant literature, or walk into an IM clinic in our neighbourhood, we are sure to find that behind all these politically correct slogans of holism and” best of all worlds” there is the coal face of pure quackery.Perhaps you don’t believe me, so go and look for yourself. I promise you will discover any unproven and disproven therapy that you can think of, anything from crystal healing to Reiki, and from homeopathy to urine-therapy.
What follows is depressingly simple: IM is a front of half-baked concepts behind which boundless quackery and bogus treatments are being promoted to unsuspecting consumers.