A chiropractor strikes back at the Institute for Science in Medicine…again

A couple of weeks ago, I had a bit of fun with a rather clueless chiropractor by the name of J.C. Smith (JCS), who decided to take a swipe at an organization with which I’m associated, namely the Institute for Science in Medicine (ISM). It was such an inept attack, filled with misinformation, pseudoscience, and logical fallacies, that it was what I like to call a “teachable moment” when it comes to chiropractors and chiropractic. Even more amusingly, JCS promised at the end of his post lambasting ISM as a new “medical mafia” that he would be writing a followup post. I could hardly wait. The only thing that disappointed me was that it took him so long to deliver.

But deliver he has, finally, much to my amusement and, I must confess, disappointment.

You see, I had expected something a bit more clever, a bit more difficult to dispose of. Don’t ask me why. I really don’t know. Perhaps hope springs eternal I just figured that if you’re going to plug a followup post, you should try to make sure it’s at least as good as the original, preferably better. In this case, even as an example of chiropractic crankery, The Medical Goodfellas, Part 2 falls flat. Or is it Three Unwise Monkeys? Both titles are used, and both are equally silly, at least as silly as Smith’s broadside at ISM that labels it a “dangerously deceptive organization.” Once again, before I dig in to this delectable bit of chiropractic crankitude, I need to point out that I do not speak for ISM, even though I am a member. The following opinions are mine and mine alone, not those of the ISM.

JCS begins:

The Institute of Science in Medicine (ISM) is a dangerously deceptive organization that hides behind an illusion of medical watchdogs to “protect the public from the predations of anti-, non-, and pseudo-scientific practices.”

Gee, he says that last part as though it were a bad thing! What’s wrong with wanting to help protect the public from the preations of anti-, non- and pseudo-scientific practices”? Personally, I think that’s a very good and noble goal to pursue. Apparently JCS does not. In fact, he has a real bug up his posterior about ISM. I suppose that’s not surprising, given that ISM is dedicated to medicine based as much as possible on science and chiropractic is infused with pseudoscience in its very essence. Perhaps that’s how JCS can write something like this with a straight face:

Of course, the ISM alone determines what qualifies one method as “pseudo-scientific practices” and the others as “scientific.” Just like its predecessors—the Medical Mussolini, the CoQ, and Stephen Barrett—these current ISM GoodFellas continue to take cheap shots at chiropractors allthewhile ignoring the medical spine care problems.

Certainly the most glaring problem with ISM is that it is not its role to act as watchdogs since this is a governmental issue within each state. No one has endowed ISM to act as such, but the AMA has never subjected its power to any governmental agency in its quest to remain the medical monopoly.

This is, of course, a massive straw man that misses the point of a policy institute. Policy institutes make policy recommendations and publish position papers. That does not mean that ISM believes that it, and it alone, determines what qualifies as pseudoscience and what does not. It means that ISM declares its position on what the science says and what policies it thinks advisable. This is not the same thing as declaring what is and is not pseudoscience with a belief in its own infallibility akin to the infallibility in matters of doctrine attributed to the Pope by the Catholic Church. In addition, where on earth did JCS get the idea that ISM would be trying to take on a role that is appropriately carried out by governmental organizations. Nowhere does it claim to do that?

As for “cheap shots” at chiropractors, where on earth does ISM do that? There isn’t even yet a policy statement on white paper on chiropractic on the ISM website! Of course, the fellows of the ISM are a group of doctors dedicated to promoting science-based medicine. That much is certainly true, but where’s all the unrelenting “hostility” to chiropractic. It’s not there, at least not right now.

So how does JCS justify his paranoia? Easy. He trots out the same tired, old attacks on science-based medicine (SBM) and evidence-based medicine (EBM) that pretty much all practitioners of unscientific medicine parrot time and time again. First, there’s the attempt to claim hypocrisy because there are modalities in medicine that are not as science-based as we would like. Of course, the problem with these attacks is that it is not quacks who discover and report the shortcomings of SBM. It’s certainly not chiropractors. Rather, it’s scientists and physicians who, as they investigate, find areas where physicians could do better. Meanwhile, JCS parrots a common fallacy:

Eddy believes only 15% of medicine is based on evidence while more optimistic ethicists claim no more than 25% of medical care is based on actual science, suggesting 75% of medical care is baseless.

Steve Novella demolished this particular canard long ago, pointing out that that mythical “15%” figure comes from a small survey of primary practice offices conducted in 1961 in the north of England. It was never intended to assess the degree to which primary care practices were evidence-based but rather was designed to study whether treatments were “specific” only from the point of view of insurance reimbursement. In other words, like so many attacks on SBM, this number comes from an obscure (and very old) source and has mutated far beyond what the original study actually found. In that, it’s like the claim that only “25%” of doctors would take chemotherapy for cancer, which similarly came from an old survey that looked at a specific chemotherapy that was new (and not entirely proven) at the time.. In reality, the percentage of medical interventions with a compelling evidence base behind them is not 15% but probably closer to 78%.

JCS also cites Gary Null, specifically “Death by Medicine,” by Gary Null, PhD, Carolyn Dean MD, ND, Martin Feldman, MD, Debora Rasio, MD, and Dorothy Smith, PhD. I’ve thought that there should be another addition to the law that says that if you cite Whale.to in a medical argument you automatically lose to include Gary Null on that list, given that his density of sheer wrongness approaches black hole levels. This particular article is one of the most amazing bits of distortion I’ve ever seen, and I’ll tell you why. It claims that 783,936 die per year due to “conventional” medicine. Now, consider this: There are only approximately 2.4 million deaths per year in the U.S., which means that, if you believe Null and company, just under 1/3 of all deaths every year are due to medical errors and adverse reactions to drugs, more deaths than occur due to heart disease (599,413) or cancer (567,628), which would make it the single largest cause of death in the U.S., and not just by a little. In fact, it’s probably worse than that, as the figures used by Null came from 2004, and the number of deaths that year was slightly smaller.

At the risk of flirting with an argument from incredulity, I have to ask: Does this sound the least bit plausible? Before you answer, consider this: Both the crude and age-adjusted death rates have been falling steadily since 1940, with age-adjusted death rates falling dramatically. Indeed, in 2010, there were 746.2 deaths per 100,000 population. Compare this to 1935, when there were 1,860.1 deaths per 100,000 population. In other words, death rates have fallen by well over 50% in a mere 75 years. That’s a massive decrease. If another source of deaths due to conventional medicine had skyrocketed to over 3/4 of a million deaths per year, then for age-adjusted death rates and overall population death rates to fall there would have to be a massive decrease in other causes of death to offset it. That just hasn’t happened. Death rates due to various causes have fallen, but not by enough to absorb an extra 3/4 million deaths a year. The bottom line is that, by any reasonable measure, death rates are falling, not rising, and there is no good evidence to suggest that one in every three people who die in a given year die because medical errors or complications from conventional medical care. In general, people are living longer than ever before. True, there are a lot of chronic health issues that plague the U.S. at a high rate, in particular obesity, which contributes to the rise in type II diabetes, but, for all its deficiencies, medicine today is far better than it was 75 years ago, and a large part of that is due to science.

Harriet Hall puts it well in her evaluation of Nulls’ “Death by Medicine”:

In the first place, how can they claim medicine does more harm than good by just listing harms? That’s like saying people buy more kumquats than artichokes and just presenting numbers for kumquat sales. You can’t say that’s “more” unless you also know what the artichoke sales figures are.

Most of their numbers are wrong. They are based on extrapolations. Even when they are more or less accurate they are misleading.

Drug reactions? All effective drugs also have side effects. It’s meaningless to count the side effects without counting the benefits. An insulin reaction counts as an adverse drug reaction, but if the patient weren’t taking insulin he probably wouldn’t be alive to have a reaction. Some of the counted drug reactions are transient minor annoyances like a rash. People have iatrogenic infections in the hospital, for instance post-op infections; but without hospitalization and surgery they might have been dead instead of infected.

Iatrogenic deaths? How many of those were of people who would have died many years earlier without modern medical care? How many of those iatrogenic causes were high-risk treatments in high-risk patients who had no other option?

No one denies that medicine is not as evidence- and science-based as it should be, least of all myself. Indeed, I’ve been known to take a swipe at procedures whose efficacy is not well supported by evidence and drug companies trying to manipulate data. However, let’s get down to the real issue and compare Smith’s favored woo, chiropractic, to SBM and ask a simple question: Which one changes and improves based on the evidence? It’s obviously not chiropractic, which has remained largely the same since D.D. Palmer first dreamed it up in the 1890s. Well, that’s not entirely true. If anything, chiropractors have gone beyond manipulative therapy to become what I like to call “physical therapists with delusions of grandeur,” going beyond the spine and musculoskeletal system to claim they can treat allergies, asthma, hypertension, and a whole host of other diseases and conditions. Some even claim they can treat autism, and many are very much antivaccine.

Now, let’s look at which one looks at patient safety seriously and tries to change practice in response to patient safety concerns. It sure isn’t chiropractic, which has at every turn, for instance, belittled and ignored concerns about strokes after neck manipulation. In fact, that’s exactly what JCS does:

Obviously these serious mistakes from medical spine care are never mentioned by ISM. Despite the huge discrepancy in medical mistakes compared to chiropractic errors, the GoodFellas are quick to use Chicken Little articles to incite mass hysteria by chanting, “Chiropractors cause strokes, chiropractors cause strokes,” allthewhile hiding the fact that there is a greater likelihood of sustaining a stroke at a hairdresser’s salon, in a dentist’s office,[20] or even a greater chance of being hit by lightning than at the hands of a chiropractor.

Indeed, where is the outcry by the ISM about the tsunami of addictive drugs, ineffective epidural shots, expensive MRI scans looking for “incidentalomas,”[21] and dangerous spine surgery based on an outdated disc theory[22]?

It amuses me greatly to see JCS opine about “outdated disc theory.” The reason, of course, is that his entire specialty is devoted to an idea that is not just “outdated” but pure fantasy. I’m referring, of course, to the idea of “subluxations,” which chiropractors claim to be able to fix. Subluxations do not exist; yet his entire specialty is constructed around the idea of them. Moreover, the most recent Cochrane review on chiropractic and low back pain concludes:

The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain. Any demonstrated differences were small and were only seen in studies with a high risk of bias.

That’s the state of the evidence as it exists now.

In other words, even for back pain, the one area where one might expect that chiropractors could do some good, the evidence for efficacy of chiropractic interventions over conventional interventions is weak to nonexistent. See why I say that most chiropractors would do a heck of a lot more good if they just became physical therapists and jettisoned the woo?

In the end, this followup post attacking ISM is risible in the extreme, relying primarily on tu quoque arguments, emphasizing harm that conventional medicine can cause while not balancing it with the good, personally attacking people like Harriet Hall and Steve Barrett, and in general using the same old fallacies favored by cranks and quacks. He even finishes up by quoting the editor of my favorite crank vanity journal of all time, Medical Hypotheses. To me, that about says it all, given that this editor, Bruce Charlton, fits the very definition of someone so open-minded that his brains fall out. Yes, SBM has its shortcomings,