Moving the goalposts (Part Two)

It’s very clear what standard of substantiation is required for claims made by chiropractors. It is in black and white in the General Chiropractic Council’s Code of Practice. Paragraph C1.6 of the CoP states that any information published by chiropractors or on their behalf, must be ‘consistent with the law and the guidance issued by the Advertising Standards Authority’ (ASA). More on this can be found in my previous post and in my complaint letter. The ASA guidance clearly says that only scientific evidence is acceptable.

However, in another bizarre statement from the GCC, it looks as if they are trying to change the meaning of the word ‘evidence’:

It does seem, however, that there may be some misunderstanding about what constitutes the practice of a reasonable chiropractor in the context of accepted modern healthcare practice.

GCC is directing its attention, therefore, to what underpins evidence based care for a variety of conditions. In line with the work of Sackett, D (2000), this will focus on “The integration of best research evidence with clinical expertise and patient values” in anticipation that we will be able to expand the information we provide to patients and the wider public.

No! It’s not about ‘what constitutes the practice of a reasonable chiropractor in the context of accepted modern healthcare practice’! It’s not the practice, it’s all about what claims can be substantiated to the level required by the chiropractors’ Code of Practice. Perhaps the GCC would be better spending their resources in ensuring their chiropractors abide by the CoP – but that’s entirely up to them.

Anyway, behind this smokescreen of trying to look as if they are doing something, they will look at the ‘best research evidence’ (although no definition of ‘best’). But why do they go and spoil it all by talking about ‘clinical experience’ and ‘patient values’? That wouldn’t be a cynical attempt to smother the scientific evidence for the lack of efficacy for chiropractic with the results of customer satisfaction surveys, would it?

They can do all that if they want, but it is a diversion from the main ‘problem’ here: that the current level of substantiation is a tad higher than customer satisfaction and chiropractors biased experiences.

As I write this, the BCA have released their ‘plethora’ of evidence for chiropractic. As can be expected, this will be taken apart in the coming days with the usual critical eye.

While this goes on, I note the first item they offer in ‘evidence’ m’lud is the entry in the GCC’s glossary for ‘evidence-based care’:

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

Not entirely dissimilar to the GCC’s pronouncement.

However, given that they choose to quote from the GCC’s CoP, I wonder why they missed out this bit:

C1.6 may publicise their practices or permit another person to do so consistent with the law and the guidance issued by the Advertising Standards Authority. If chiropractors, or others on their behalf, do publicise, the information used must be factual and verifiable. The information must not be misleading or inaccurate in any way. It must not, in any way, abuse the trust of members of the public nor exploit their lack of experience or knowledge about either health or chiropractic matters. It must not put pressure on people to use chiropractic.

Or the ASA guidance the CoP refers to:

Medical and scientific claims made about beauty and health-related products should be backed by evidence … Substantiation will be assessed by the ASA on the basis of the available scientific knowledge.

Or this bit:

Marketers should hold robust evidence for all claims.

Or this bit:

To date, the only serious medical condition to which CAP and the ASA accept chiropractors may refer is migraine (not headaches).

Or this bit:

But CAP has accepted in the past that chiropractors may claim to help: aches and pains, arthritic pain, backache, back pain, circulatory problems, cramp, digestion problems, joint pains, lumbago, muscle spasms, neuralgia, fibromyalgia, inability to relax, rheumatic pain, rheumatism, minor sports injuries and tension (see General List in the Help Note on Health, Beauty and Slimming Marketing Communications that Refers to Medical Conditions).

Practitioners claiming to treat such conditions would be expected to hold evidence.

Now, they’re not cherry-picking, are they?

More tomorrow.

24 thoughts on “Moving the goalposts (Part Two)”

  1. So, is guarding the right of science journalists to tell the truth about potential malpractice applied to infants, less important than owing a cat?

    Shame on you.

  2. Instead if getting a cat myself I had a closer look at the omnibus complaint. It seems very vexatious, which weakens its validity. The majority of the chiropractors in the omnibus complaint had no mention of infants. Only MSK complaints.

    So do they have nothing to worry about? Only the stress of answering a complaint, the monetary cost to the individual, profession and government regulator.

    Those that have made claims of treating infant colic need to show evidence. Clearly they (the chiropractic profession) needs to find a way of regulating their scope of practice more tightly.

    It looks like she has gone out to bankrupt the profession. The complainant should withdraw her complaints against those with only MSK disorders listed. This would have support from the chiropractors I see for my back pain(there, I have declared my interest!).

    I of course support Simon Singh and any scientist to criticise rationally. This omnibus complaint smacks me as irrational action in some parts. More part of an organised campaign to destroy a profession in revenge for a misguided libel case action by their association.
    Why is there no mention of Osteopathy, who seem altogether more woo woo with their cranial treatments etc of children and naturopathic tenancies?

  3. The BCA produced their "evidence" yesterday. It's been shredded by a few bloggers esp DC.
    My paediatrician colleague describes it as weak.
    My own judgement of it is that it is weak evidence, but some of the studies would encourage further research.
    But weak is not the same as "not a jot" which Simon states in his article.

  4. The complaint doesn’t look vexatious to me. It isn’t about infants, it’s about failing to adhere to GCC’s Code of Practice. What exactly is the point of having a Code of Practice if these people can get away with breaking it?

  5. The complaint is clearly vexatious and we all knows that. The chiropractors on the list have not broken ASA guidance and therefore are not in breach of the GCC code. The ASA rules are an issue for all independent practitioners including chiropractors, osteopaths, physiotherapists, dentists etc and it would be easy to put in a raft of complaints against any or all of these professions. This is partly because the ASA guidance is outdated and you cannot find out what evidence they hold. Additionally, the validity of the ASA decisions has been put in doubt by their use of Ernst as an expert. He has never demonstrated an objective or balanced approach in his assessment of chiropractic.

    I hope that the eventual outcome of this affair will be a more level playing field for all of the professions mentioned above and better guidance from the ASA.

  6. How do we all know that the complaint is 'clearly vexatious'?

    How do you know they haven't broken ASA guidance?

    Why are the ASA rules an issue for all 'independent practitioners'?

    Are you about to complain against dentists, etc since it would be so easy?

    What ASA guidance is out of date? (I assume you got your comments on the review of the CAP today?)

    You misunderstand how the ASA work: an advertiser makes a claim – it is the advertiser that has to provide the evidence to back up that claim, not for the ASA to hold data.

    If you have evidence that Ernst is not objective or balanced, please let us know what that evidence is.

    As Skepticat said, there is a CoP that chiropractors are supposed to follow. If they have the appropriate substantiation for any particular claim, then their complaint will not be upheld.

  7. I have notification of Zeno's complaint against me from the GCC.

    It won't be upheld as the conditions listed on which I have to provide substantiation are all MSK and well within the CoP. I don't call myself Dr either.

    No problem then? Apart from the cost to my insurers providing legal advice for my reply/comments, the cost of time out of practice for me to meet the solicitor and prepare my comments etc, the cost to the BCA assisting me, the cost to the GCC in their investigations etc

    This is going to be repeated at great cost for many chiropractors who have done nothing wrong but who have had a complaint made against them.

    There are some chiropractors who may have a case to answer. But to have many included who obviously don't appears vexatious. And as Prof Hirst says above, weakens the complaint itself.

  8. I've just seen my Dentist, Dr Hull at his dentistry practice. I didn't for a moment think he was a GP. I cannot imagine anyone ever would.

    Does anyone have a problem with that?

  9. Chiro, as the conditions on which you provide substantiation are "well within the CoP", why do you need legal advice for your reply? Just provide the best scientific evidence for what you are doing and you'll be fine. I'm sure all these chiropractors who have done nothing wrong are pefectly able to substantiate the treatments they are promoting, otherwise they wouldn't be promoting them, would they?

    Frankily, moaning about having to play lawyers etc doesn't do you any favours. If you have the ability to set yourself up as a professional healthcare practitioner, you surely have the ability to defend yourself against a "vexatious" complaint without bothering your insurers.

    In fact, let me know what conditions you claim to treat and have to provide substantiation for and I'll seek out the scientific support for it without your having to pay me a penny.


  10. It is a requirement of the GCC complaint process that my insurers are informed. The insurer provides legal advice to answer complaint as a matter of course.
    I think I had better rely on them for my defence – but your offer is appreciated. I will let you know how it goes.
    The GCC, BCA and I will also incur costs. I will let you know how much these are too.

  11. You're welcome.

    It seems a bit daft to provide costly legal advice "as a matter of course" when even none is needed but that would be seem to be something to moan to the GCC- rather than the complainant – about.

  12. Even dentists have to be clear when they use the courtesy title 'Dr'. The ASA says:

    "Advertisers who are not medical practitioners but who hold the courtesy title “Dr” (for example, a chiropractor or a dentist) may refer to themselves as “Dr” as long as the similarities and differences between the practitioner’s qualifications and medical qualifications are explained in detail in the advertisement (Midland Chiropractic Group, 28 February 2001). Such explanation should go substantially further than, for example, simply stating “Dr is a courtesy title” in a footnote. The latter is likely to contradict the initial impression, given by the use of the title “Dr”, that the practitioner is medically qualified."

  13. I fail to see Andy's point. Of course nobody is going to mistake their dentist for a GP. GPs, in my experience, don't sit their patients in a dentist's chair and start drilling their teeth.

    Chiropractics who call themselves 'Dr.' and claim to treat a range of medical conditions are being deliberately misleading. I have been misled myself by this custom. Only relatively recently did I learn that these people are not medically qualified.

  14. Here are two comments on Ernst:

    Review conclusions by Ernst and Canter regarding spinal
    manipulation refuted
    Gert Bronfort*1, Mitchell Haas2, David Moher3, Lex Bouter4, Maurits van
    Tulder4, John Triano5, Willem JJ Assendelft6, Roni Evans1, Simon Dagenais3
    and Anthony Rosner

    The conclusions by Ernst and Canter were definitely not
    based on an acceptable quality review of systematic
    reviews and should be interpreted very critically by the scientific
    community, clinicians, patients, and health policy
    makers. Their conclusions are certainly not valid enough
    to discredit the large body of professionals utilizing spinal

    Evidence for manipulation is stronger than that for most orthodox medical treatments
    British Medical Journal , Jan 23, 1999 by Gordon Waddell

    As one of the coauthors of the Clinical Standards Advisory Group's report on back pain[1] and the Royal College of General Practitioners' guidelines on acute low back pain,[2] I am disappointed by Ernst and Assendelft's editorial on chiropractic.[3] The authors present a critical view of chiropractic under the guise of scientific objectivity, but I had hoped that we had got beyond that stage of interprofessional confrontation.
    Burton and I recently reviewed international guidelines for low back pain, and none of them specifically recommend chiropractic.[4] What they do all say, and what all recent reviews conclude to varying degrees, is that considerable evidence now exists that manipulation is an effective treatment for low back pain. Indeed, there is stronger evidence for manipulation than for most orthodox medical treatments. The guidelines also advise that manipulation should be performed by a trained professional but that there is no clear evidence whether it is better performed by a chiropractor, an osteopath, a physiotherapist, or a doctor with special training.
    Ernst and Assendelft's review of the risks of manipulation is particularly biased. Although the subject of this editorial is low back pain, they concentrate on the admittedly higher risks of cervical manipulation. Even then, orthodox medicine has a long way to go to reduce the rate of serious complications of most of our investigations and treatments to the order of 1:0.2-1 million. The adverse reactions to which the authors refer are temporary aggravations of symptoms or minor subjective reactions; in a personal series, that rate is comparable to figures for every other orthodox treatment for back pain. What matters is the balance of effectiveness versus risk, and that is strongly in favour of manipulation. The politics and costs of any NHS provision of a service are a completely separate and more relevant debate.
    None of us have a good answer for low back pain–orthodox medicine, professors, and methodologists least of all. Chiropractic is not the magic answer for back pain, and it should and can stand up to fair criticism, but orthodox medicine could potentially also learn a lot from chiropractic.[5] The needs of patients with back pain should override our professional dignities, and the real need is for us all to work together. That cooperation is not likely to be helped by this kind of editorial.
    [1] Clinical Standards Advisory Group. Report on back pain. London: HMSO, 1994.
    [2] Royal College of General Practitioners. Clinical guidelines for the management of acute low back pain. London: RCGP, 1996.
    [3] Ernst E, Assendelft WJJ. Chiropractic for low back pain. BMJ 1998;317:160. (18 July.)
    [4] Burton AK, Waddell G. Clinical guidelines in the management of low back pain. In: Nordin M, ed. New approaches to the low back pain patient. London: Bailliere Tindall, 1998:17-35. (Bailliere's clinical rheumatology.)
    [5] Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone, 1998.
    Gordon Waddell Orthopaedic surgeon
    Glasgow Nuffield Hospital, Glasgow G12 0PJ

  15. So skepticat, you would think a Chiropractor working in a Chiropractic clinc, who puts you on a chiropractic bench and uses spinal manipulation, is more difficult to distinguish from a GP than the process at the dentist you describe.
    I'm not convinced.
    My dentist also lists the following medical conditions "headaches, infections". I still wasn't confused by their use of the term Dr and thought they were masquerading as medics.

  16. Zeno

    The vexatios nature of your complaint is clear to see.

    The chiropractors have not broken ASA rules as ASA rules do not apply to websites. With copy advertising the ASA will assist and advise on the advert in question. This is not the case with web sites as they are not regarded as advertising. If they have not broken ASA guidelines then they are not in breach of GCC cop providing they can substantiate their claims.

    ASA guidelines relate to all independent practitioners- I have contacted the ASA to ask about claims made by physiotherapists and osteopaths and the ASA relpied that they did not hold evidence to support some of their claims.

    ASA guidelines are out of date-if we consider whiplash and arthrits this has now been covered by recent research papers and guidelines endorsing manipulation. Clearly Ernst had an influence on the ASA guidelines. His objectivity has been discussed above but now ASA guidelines are at odds with national guidelines and best available evidence.

  17. You obviously have not read the GCC's Code of Practice that chiropractors have signed up to, nor my complaint.

    If you had, you would have known that the CoP mandates all claims made by chirpractors to be compliant with ASA guidelines. That is not ASA rules, but the GCC's.

    It is not up to the ASA to hold evidence for an advertiser's claims: it is the advertiser who must hold that evidence before he/she makes that claim.

  18. Which bit of paragraph C1.6 of the GCC's CoP do you think is open to interpretation?

    "C1.6 may publicise their practices or permit another person to do so consistent with the law and the guidance issued by the Advertising Standards Authority."

  19. Sorry Andy, I've only just seen your last comment.

    I wonder…are you a bit thick or just being deliberately obtuse?

    No, I wouldn't think a chiropractic who puts me on a bench and uses spinal manipulation is difficult to distinguish from a GP, nor did I suggest any such thing.

    But if someone calls themself 'Dr' and claims to be able to treat a range of medical conditions some of which are not even muscular-skeletal,then I don't think I'd be the only one to assume that they are doctors of medicine rather than doctors of chiropractic and chiroquacks know this. That's why to do so is to be deliberately misleading.

    Got it now?

  20. Just countering your assertion that the reason you knew they were Dentists was because they put you on a dentists chair and drill your teeth.
    They also call themselves Drs and claim to treat medical conditions not restricted to the teeth.

    I am, of course, playing devils advocate. And no I'm not thick.

    I don't think Chiropractors try and deliberately mislead people into thinking they are medical doctors. More they are trying to claim their professional education is deserving of the title like GPs, Dentists, Vets etc – a subtle but important difference.

    If you want to say it doesn't, and in this country you could argue that as the standard of student is inferior for a start, I would say you have a better case.

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