The random thoughts of a sceptical activist

The beginning of the end?

The first decisions of the GCC’s Investigating Committee (IC) on my complaints fell with a thud onto my doormat a few days ago.

I received copies of 43 letters sent to 43 of the chiropractors I complained about. All were notifications that the IC (which consists of eight chiropractors and four lay members) had decided — for various reasons — that there was no case to answer and that, therefore, no further action would be taken against them.

Eight of them were thrown out (leaving 35), the IC reasoning:

The extracts from the website, submitted in support of the complaint against you, related to a time you had ceased working at the clinic in question and therefore at a time when you were not responsible for the website content. For this reason the Investigating Committee has concluded that there is no case to answer in respect of the complaint against you.

I’ll leave it to you to tease out the issues I might have with that.

I’ll be saying more about the details of the other letters later, but I thought I’d share some of the gems to be found within them.

The law

After some preamble, they get off to a good start, citing the relevant clause of their Code of Practice that chiropractors are bound to comply with:

C1.6 of the Code of Practice states that chiropractors -

‘may publicise their practices or permit another person to do so consistent with the law…”

All well and good. Except…that’s not all C1.6 says. It continues:

…and the guidance issued by the Advertising Standards Authority.

And indeed, that’s what my complaint was all about: that they were making claims that I believed went against guidance issued by the ASA.

So why cut it short? Why ignore whether or not the claims complied with ASA guidance? Do they think that requirement is somehow null and void; something to be ignored without justification? Publicity has to comply with both requirements not just one.

More questions needing an answer.

However, they go on to say:

In the context of the relevant law (The Consumer Protection from Unfair Trading Regulations 2008) advertised claims for chiropractic care must be based on best research of the highest standard. This will almost certainly mean randomised controlled trials that produce high or moderate positive evidence. (Link added)

Now we know what law they think is relevant. At least they mention ‘the best research of the highest standard’ and that this (almost certainly) means RCTs that give good evidence.

Expertise and preferences

But what about the Code of Practice whose glossary defines evidence-based care, cited by many chiropractors in their observations, as:

clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners (including the individual chiropractor her/himself).

All the 35 letters stated the following:

The other elements of evidence based care as it relates to clinical practice (the preferences of the patient and the expertise of practitioners (including the individual chiropractor her/himself)) are, of themselves, insufficient to support advertised claims.

No matter what a chiropractor might think; no matter what a chiropractor might have seen with his or her very own eyes; no matter what he or she believes might work; no matter what a customer might prefer — none of these are sufficient to back up claims in any publicity. All claims must be supported by robust evidence, and that severely limits what many chiropractors can now get away with claiming.

About time too.

There is, of course, a subtle difference between what a chiropractor is allowed to advertise and what he or she actually tells customers and what they do in their clinics. My complaints were about what they were advertising; what they were using to pull in new customers. I have no idea what goes on within the four walls of the clinics, although Skepticat has first hand experience of one.

However, it would be utterly perverse if what they were allowed — tacitly or otherwise — to practice was in any way different to what they were allowed to tell people they were allowed to practice.

What about the kids?

Many of the letters mentioned that the chiropractor had said something on his or her website about children and babies. One example:

The Investigating Committee did note the reference to ‘Paediatric care’. The Investigating Committee considered that this could give a member of the public reading the webpage the impression that you provide treatment to babies.

Other letters mentioned similar claims about children. Despite the fact that Bronfort found that there was no good evidence that chiropractic worked for children or babies for any condition, the GCC have taken the opportunity to remind all the chiropractors:

It was mindful that there is no high or moderate positive evidence from randomised controlled trials that would support a claim to treat children using manual therapy. In the absence of such evidence, it concluded that it could be inappropriate to make such an advertised claim.

An odd choice of phrase, ‘could be inappropriate’, but the meaning is all too clear: there is no evidence for treating children with chiropractic. Not a jot. Not for colic; not for bed wetting; not for hyperactivity; not for feeding problems; not for sleeping problems. Not for any condition.

Chiropractors should therefore not be making any claims for children.

But isn’t it odd that they managed to decide that unsupported claims were being made, but still found no case to answer?

Good advice

In addition to the specific guidance offered to the 35, the GCC chose to deliver the following message to all 43 chiropractors — the ones they’ve decided have no case to answer:

The Investigating Committee recommends that you carefully consider the guidance issued to the chiropractic profession by the General Chiropractic Council in February/March 2010 and that you ensure that any advertisement of your services complies with C1.6 of the Code of Practice. (the GCC’s underlining)

Taken individually and together, these are welcome steps in the right direction.

But there is much more to come.

39 Responses to The beginning of the end?

  • @zeno
    you may find that in clinical life, there are sometimes differences for what one can find research about and what one may experience. Unfortunately the experience always preceeds the science and conversely the lack of science does not preclude the experience. Advertisment regulations are an ASA matter and the ASA requires high standard research. This therefore precludes certain claims to be advertised as it would be illegal to do otherwise. It does not however preclude clincal experience.
    There is a serious distinction to be made between the two
    Kind regards,
    Stefaan

  • Zeno wrote: “There is, of course, a subtle difference between what a chiropractor is *allowed to advertise* and what he or she actually tells customers and what they do in their clinics. My complaints were about what they were advertising; what they were using to pull in new customers. I have no idea what goes on within the four walls of the clinics, although Skepticat has first hand experience of one. However, it would be utterly perverse if what they were allowed — tacitly or otherwise — to practice *was in any way different* to what they were allowed to tell people they were allowed to practice.”

    I think you’ve nailed it, Zeno. Here’s what a former chiropractor answered in response to a question on that very issue on his blog today:

    Quote
    [Q] “If the GCC is so confident of medipractic (science based chiropractic), why do they allow traditional chiropractic to continue in practice (even if you can’t advertise it) – that seems unethical if they are right”

    [A] “Mooooooooooooooooooney” what Sid Williams called the money hum.”

    http://www.chiropracticlive.com/?p=767

    More about ‘the money hum’ here:
    http://www.chirobase.org/03Edu/moneyhum.html

    Scandalous.

  • @ anybody following this thread….

    Can you see a pattern to Blue Wode’s contributions to this blog? It seems quite obvious to me that his/her sole intent is to denigrate chiropractic at any and every opportunity, shoehorning irrelevant quotes and references in wherever possible.

    One really has to wonder what the motive is. Personally, I find it hard to believe that it’s public interest; it has all the hallmarks of pure malice as far as I can tell.

    I would be interested in readers’ thoughts, other than Blue Wode’s of course.

  • David

    Attacking the messenger is usually the last refuge of someone who can’t engage with the argument (see the Comment Guide) and I’m not sure anyone really interested in what you personally find believable or otherwise.

    If you think a quote or reference is irrelevant, please just say so and give your reasons.

  • @ Zeno,

    My point is that Blue Wode’s last several contributions have not been relevant to the topic, they have simply been opportunistic jibes at the chiropractic profession.

    So, I am just “saying so, and giving my reasons”

  • Which ‘several contributions’? He’s only had one on this post.

    However, saying you think any comment is not relevant does not make it so and you still have not given any reason.

    Blue Wode said:

    Here’s what a former chiropractor answered in response to a question on that very issue on his blog today:

    What do you see as the problem with that?

  • @David

    Blue Wode seems to make reasonable comments. She/he may denigrate chiropractic, but surely it’s fallacious reasoning to then conclude this is the sole intent. The fact this blog is read by the public implies that it is of public interest.

  • @ Andrew Gilbey,

    My conclusions are based on evidence. Evidence based deduction, if you like! I think that few could genuinely believe that the intent is other than malicious.

    It’s a shame, because I thought that the intention here was to make things better.

  • David

    What evidence?

  • @ Zeno

    You’re being deliberately obtuse and I’m not about to give Blue Wode’s propoganda yet another airing by listing all the irrelevant and spurious points s/he’s used your forum to make.

  • The beginning of the end?
    How about someone actually begins with the beginning of the beginning: What do you understand chiropractic theory to be and can you provide sound and relevant references?
    I have asked this question from Andrew Gilbey, Zeno, Blue Wode and Skepticat,… none of whom have responded to this.
    I am wondering whether they actually know what it is they are critiquing.
    Kind regards,
    Stefaan

  • @ David

    I am for freedom of informed choice.

    It is not in the emotional or financial interests of CAM practitioners (chiropractors included) to inform the public about the lack of evidence for their various interventions. As a result, it is often left to members of the public themselves to learn how to make informed choices if they are to avoid inappropriate and costly treatments. As I cannot abide dishonesty, I am more than willing to help them with that.

  • David said:

    You’re being deliberately obtuse and I’m not about to give Blue Wode’s propoganda yet another airing by listing all the irrelevant and spurious points s/he’s used your forum to make.

    No, David. You have been asked several times now to give a reason for your belief about Blue Wode, yet you refuse to share it.

    Stefaan said:

    The beginning of the end?
    How about someone actually begins with the beginning of the beginning: What do you understand chiropractic theory to be and can you provide sound and relevant references?
    I have asked this question from Andrew Gilbey, Zeno, Blue Wode and Skepticat,… none of whom have responded to this.
    I am wondering whether they actually know what it is they are critiquing.

    It doesn’t matter what I think chiropractic ‘theory’ is, particularly when it looks like the chiropractic industry can’t even agree on what it is and when many chiropractors seem to disagree with the statutory regulator about what chiropractic is and does!

    Instead of asking us, have you tried asking your regulator? They’re the ones who make — and change — the rules after all.

  • @zeno
    you are ill-informed, the regulator does not do that. As I have said before you will find the GCC unable to answer that question as it is not in their remit. I think it actually is very relevant what you think it is as it that which you are critiquing. So what do you think it is?

  • @ Blue Wode

    That’s a straight-forward accusation of dishonesty and a strong suggestion that chiropractors’ sole purpose in practice is to relieve patients of thier money. I hope you’ve got the evidence to back that up.

    Believe me, if I was interseted only in making money, I would have, and still could do something else much more profitable. No, the reason I and everyone else I know, went into chiropractic was because it is a modern, safe, effective, satisfying branch of neuromusculoskeletal healthcare. Despite all your propoganda.

  • Zeno said: “Have you tried asking your regulator? They’re the ones who make — and change — the rules after all.”

    SV said: “you are ill-informed, the regulator does not do that.”

    The GCC doesn’t make and change the rules?

    So who does?

    I thought all the complaints are about chiropractors making unsupportable claims on their website, regardless of what ‘chiropractic theory’ is.

    Looks like a red herring to me.

  • Hi Arthur,
    not quite a red-herring. The GCC enforces ASA rules. The ASA makes the rules in regards to advertising claims, not the GCC. Those rules say that there has to be high-end scientific evidence for the claim to be advertised.
    The GCC makes the rules about how to enforce the standards of care and tells us what we can and cannot do. Amongst those rules we have to obey ASA standards. The GCC was the point of complaint for zeno and simon perry and they pulled the GCC up on its lack of enforcement of this ASA rule. There is no real success in this other than that they rightly pointed out the obvious to a profession that was too blind to see it.
    KR
    Stefaan
    This is only the beginning

  • SV, thank you or the explanation but I still don’t see the relevance of your question, “what do you think chiropractic theory is,” therefore it still looks like a red herring to me.

    @David

    So do you think it is in the financial interests of CAM practitioners to “inform the public about the lack of evidence for their various interventions”?

    If so, why don’t they do this?

  • Hi Arthur,
    I think it’s just a case of actually understanding what it is they are exactly disputing or discussing. Often times the people on sites like these switch arguments against the theory to be arguments against the practice and vice-versa. So the first thing I wanted to establish is what is their understanding of the theory and then the next step is to understand what their understanding of the practice is. Separating these two is very important as chiropractic as a profession is not yet able to practice fully its theory. The chasm existing between the two is what research is needed for.
    KR
    Stefaan
    ps the lack of evidence really does not deter the patient. Lack of results does. Patients are individuals who are seeking a product (usually relief from back pain). The vast majority of these individuals get the results they seek. Therefore the word of mouth produces plenty of work.

  • @ Arthur

    “So do you think it is in the financial interests of CAM practitioners to “inform the public about the lack of evidence for their various interventions”?”

    It is certainly in the financial interests of chiropractors to inform their patients about the benefits and risks of their various interventions. This will inevitably involve the evidence for and against any procedure but this evidence can and does include clinical experience; it does not have to be based on RCT evidence alone.

    When it comes to advertising one’s practice, the ASA insist that claims should be made only for interventions that can be backed up by RCT quality evidence. When it comes to clinical practice, it is what’s best for the patient that’s important, whether it has been tested in RCTs or not.

    My practice, like those of all the other chiropractors I’ve worked with, is based on recommendation from patients and other healthcare practitioners who refer new patients to us.

    Our reputation is what keeps the practice going and that is built on trust. We honour that trust invested in us by our patients and the general public and so, yes it is in our financial interest to be honest.

  • Stefaan

    I disputed the claims many chiros were making on their websites and used the existing statutory mechanism for such complaints, presumably set up for that very purpose. Many of these claims appeared to be in contravention of the Code of Practice chiros are supposed to be bound to. My understanding of what a subluxation was didn’t feature in my complaints.

    Of course, we’ve still to find out what the GCC think of the majority of my complaints, but we do know that the majority of Simon Perry’s complaints will be considered by the PCC. Some may even be found to be guilty of ‘unacceptable professional conduct’.

    But before the GCC were able to decide whether the claims being made were backed up by robust evidence or not, they needed to ask someone else, presumably because — like ‘subluxations’ — they hadn’t previously considered what their charges could and could not claim, despite the CoP.

    I assume you have read and understood what they GCC are saying about the beliefs and expertise of chiros and patient expectations as a basis for the evidence for claims?

    The GCC — your statutory regulator — has now spoken on what they believe the evidence substantiates, so, if you don’t agree with their conclusions, it’s them you need to be arguing with, not the sceptics.

  • @ David

    You wrote: “…this evidence can and does include clinical experience; it does not have to be based on RCT evidence alone. When it comes to advertising one’s practice, the ASA insist that claims should be made only for interventions that can be backed up by RCT quality evidence. When it comes to clinical practice, it is what’s best for the patient that’s important, whether it has been tested in RCTs or not. My practice, like those of all the other chiropractors I’ve worked with, *is based on recommendation from patients and other healthcare practitioners who refer new patients to us*.”

    But are you factoring in the following?

    Quote
    “Those who cast doubt on fringe treatments are frequently dismissed with the rejoinder, “I don’t care what your research studies say; I know it worked for me.” It is well established, however, that this kind of intuitive judgement often leads to seriously flawed conclusions. [56,57] Unfortunately, the typical purveyor and purchaser of unproven therapies is insufficiently aware of the many perceptual and cognitive biases that can lead to faulty decisions when we depend on personal experience to decide what has caused a disease or whether a therapy “has worked” or not. Redelmeier and Tversky [58] showed how people are prone to perceive illusory correlations in random sequences of events. They then demonstrated how these intuitive feelings of association have led to the false but widespread belief that arthritis pain is influenced by the weather. Proponents of CAM, who take many folk beliefs like this at face value, seem oblivious to how easy it is to be misled by uncontrolled observations and misrecollections such as these.”

    Social and Judgmental Biases That Make Inert Treatments Seem to Work
    http://www.sram.org/0302/bias.html

    As regards the healthcare practitioners who, you say, refer new patients to you, it has been pointed out before that it’s quite possible that they could be unloading intractable, self-limiting cases on you for placebo “treatments”. In which case, that would not really be an endorsement of chiropractic as much as an acknowledgment that chiropractic clinics are repositories for people who really need no treatment (with the hope they will not be harmed).

  • @zeno
    so in essence you achieved what you set out to do… I have thanked you for that in the past as I think it is very useful to the profession as a whole. I have read and understood the GCC statement and agree that it is an historical concept but remains a theoretical model. I also agree that chiropractors shouldn’t advertise to treat asthma, colic et al, in fact I think they shouldn’t advertise to treat anything, but none of this compiles to a feeling of argument… but rather agreement. Neither does it compile to any sense of finality for the chiropractic profession. In fact, it heralds the return to core values of chiropractic. that’s why this really only is the beginning… Hence why my question on your understanding of those core values, as I am failing to see the reason you would put this much effort, even after having achieved your goal, if it wasn’t for the fact that you have a more fundamental discomfort or disagreement with the profession. You have helped highlight issues with its behaviour, but continue debate, so there must be something about its content that finds disagreement in you. Or was the intellectual exercise through the GCC really all this is about?

    Stefaan

  • @ Blue Wode

    I suspect that you have a smile to yourself when you put up these nonsensical distractions.

    My point, as you will undoubtedly know, is that effective therapetic procedures are still effective therapeutic procedures whether they have yet been tested in RCTs or not. Chiropractic practice includes ALL the available evidence whether it be RCT or otherwise. The correct approach in healthcare is to do what’s best for the patient and every frontline clinician (and most patients) will know that that means taking note of clinical experience as well as pure research.

    As regards the GPs, consultants, nurse practitioners, dentists and physiotherapists who refer me patients, you are clutching at straws in your suggestion that they are simply unloading patients. Although, it is of course true that the main reason they refer them to me is because they have been unable to help them themselves. What explanation can you come up with for the fact that these people don’t just refer me patients, they come to me as patients as well?

  • @David
    nice point, but I am sure that BW will be looking at it as their own personal bias, lead by the reported experiences of their own patients (and being primarily British these will tend to be the positive reports-as you Brits are far too considerate to go to someone and say “hey that was a rubbish referral”-cultural bias?). Much in the same way as the patient who has referred a patient who in turn thanked them for the referral because they are now so much better is more likely to refer another patient….
    Just anticipating…
    In fact,… come to think of it how many RCT’s have been able to “completely” eradicate possibility of bias? And do the outcome measures agree with the field-measures? Just a question…
    Kind regards,
    Stefaan

  • David said:

    @ Blue Wode

    I suspect that you have a smile to yourself when you put up these nonsensical distractions.

    You’re still doing it — why do you think his comments are nonsensical?

  • Stefaan

    Any progress on your draft study yet?

  • David wrote: “The correct approach in healthcare is to do what’s best for the patient and every frontline clinician (and most patients) will know that that means taking note of clinical experience as well as pure research.”

    I think that gets to the heart of the issue again. With the GCC readily admitting that the scope of practice for its registrants is not defined, chiropractic quackery is allowed to run rampant, e.g. craniosacral therapy and applied kinesiology both fall within the GCC’s definition of evidence-based care. See here:
    http://jdc325.files.wordpress.com/2009/06/gcc-ak.pdf

    How that could be considered as anything other than unethical is beyond me.

    David wrote: “What explanation can you come up with for the fact that these people don’t just refer me patients, they come to me as patients as well?”

    Unless they’re attending for the short-lived relief of acute low back pain, I would suggest that either their critical thinking faculties aren’t as sharp as they could be, or that (for their own reasons) they have time and money to waste on a theatrical placebo.

  • @ Zeno

    I can’t believe you really need it spelling out for you, but I’ll try.

    Blue Wode’s habit is to take a small part of whatever post s/he’s commenting on and reply with some tenuously linked quote which is largely irrelevant to the topic and generally offers only opinion rather than fact.

    S/he simply uses every post as an opportunity to introduce another strand of anti-chiropractic propaganda rather than actually engaging in debate on the current topic.

  • @ Blue Wode

    “David wrote: “What explanation can you come up with for the fact that these people don’t just refer me patients, they come to me as patients as well?”

    Unless they’re attending for the short-lived relief of acute low back pain, I would suggest that either their critical thinking faculties aren’t as sharp as they could be, or that (for their own reasons) they have time and money to waste on a theatrical placebo.”

    Like I said, you’re clutching at straws.

  • David wrote: “S/he simply uses every post as an opportunity to introduce another strand of anti-chiropractic propaganda rather than actually engaging in debate on the current topic.”

    That is not true. I introduce factual and accurate information (which I suspect chiropractors would prefer to have suppressed) which I feel is relevant and in context, and might be appreciated by un-enlightened readers.

  • @ Blue Wode

    We will have to agree to disagree.

  • @iaind
    some progress yes, but of academic nature. Would love to hear your thoughts on first proposal.
    Stefaan

  • @BW there’s really anything there that would warrant a desire to suppress the references, other than for their lack of poignancy

  • @Stefaan

    TBH, I’m not sure what to make of it. I appreciate it’s a draft but it seems complicated and I’m not sure it’s clear what it is you are trying to prove. What’s your null hypothesis?

  • From my reading of this site and comments I think Stefaan actually practices a somewhat different “Chiropractic” from that taught in U.K. & Australian colleges, with apparently better effect. Some selective trials of some techniques (e.g. the dental splints) compared against other techniques would be useful. Key things are 1. focus on a condition that it appears highly successful for; 2. randomise patients between this treatment and a more ‘conventional’ intervention that is still high impact (for similar placebo effect); 3. get an independent person who does not know which treatment was given to do the post-treatment assessment, carefully avoiding learning what treatment was given – a written standard script for the assessment is useful.
    [Disclaimer: I have only done a little official "research", but these are generic requirements for avoiding major confounding factors]

    Of course the ASA says you can’t advertise these treatments (at all, since to advertise treatment is to imply effectiveness according to the ASA) until you have formally gathered such evidence, and the GCC says you can’t publicise the treatments until then.

  • Blue Wode: Wednesday 30 June 2010 at 13:08 Well put. Even homeopaths, acupuncturists, clairvoyants craniosacral therapists and applied kinesiologists have satisfied customers and believe they are doing good.

    David, BW’s post was not a distraction – you and your patients are capable of being deceived by experience. In the 1960′s surgeons were convinced that it did good to graft a stomach artery to the cardiac arteries. You could be sued for not recommending the operation. It took an RCT (of open heart surgery!) to show they were mistaken.

    Stefaan said “they rightly pointed out the obvious to a profession that was too blind to see it” – very true. Zeno’s comment,Wednesday 30 June 2010 at 13:01, reminds us that he got here from the ASA rules – he’s made ASA complaints about many other things.

    “what do you think chiropractic theory is” is irrelevant – whatever Chiropractors do, they are required to hold solid evidence for it before they advertise it as a treatment for anything. The GCC investigating comittee seems to have missed this point.

    I don’t think Zeno has achieved his first point, which was that Chirporactors were flouting the ASA rules (witness the several rulings against them), but the GCC was not enforcing thir CoP that required following the ASA rules in all communications. The investigating comittee, by saying there is no case to answer for people who have made non-evidence backed website claims, has declared that breaches of the CoP need not result in an Professional Conduct Committee case.

  • @ Zeno

    Just found out that the GCC, after taking legal advice, cannot go ahead with your complaints. Any conditions which they were promoting/endorsing at the time of your omnibus complaint prohibits them from disciplining those chiros that were simply following their example.

    They can,however, press ahead with other claims made on websites which they themselves heroically unearthed, rigorously protecting the general public.

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