Journal of Manipulative and Physiological Therapeutics
Volume 31, Issue 8 , Pages 559-561, October 2008

Keeping a Critical Eye on Chiropractic

Editor JMPT, National University of Health Sciences, Lombard, Ill

Article Outline

Abstract 

This article discusses the importance of professional self-regulation and critical appraisal of information. A list of red flags is offered that could be used when analyzing information, scientific articles, or attending educational events.

Key Indexing Terms: History of Medicine, Chiropractic, Evidence-Based Medicine, Complementary Therapies

 

Who should keep a critical eye on chiropractic? Those outside of the chiropractic profession (eg, laypersons, lawyers, and other health care providers) have kept a critical eye on chiropractic activities for the past 110 years.1 It is important to note that the medical profession's criticism of those who were not medically educated and practiced in a different manner existed long before the birth of chiropractic. For example, a Committee on Quack Medicines was noted in 1828,2 a Committee on Medical Reform was created in London in 1837,3 and in 1857, “a committee on Quackery who shall report on the number and character of quacks, also the means resorted to by them in order to obtain business …,” was developed.4 The editors of the Cincinnati Medical Observer exemplified how members of a profession regulate their own when they declared, “We intend to wage an increasing opposition against quacks and quackery in the regular profession, who attempt to hide its ugly practices under the mantle of respectability.”4 There were good reasons for concern about health care. In the mid-19th century in America, there were various types of practitioners who called themselves “doctor,” but many had little or no training, thus, causing a risk to public health. Medical practice was unregulated and harmful treatments were commonly used; thus, patients were at the mercy of their doctor to provide them with safe and effective care.5, 6

Regular (allopathic) physicians kept a watchful eye on those who were not medically trained. Those being watched were known as “irregulars” such as homeopaths, hydropaths, eclectics, and, in the latter part of the 19th century, osteopaths and chiropractors.5, 6, 7 In 1847, the newly developed American Medical Association (AMA) crafted a code of ethics to help unify the medical profession. Among a list of various actions, the code required regular doctors to reject providers not trained in the “regular” manner, to denounce the use of inappropriate advertising, and to practice using a scientific basis.8 It is interesting to note that although the 1847 AMA code demanded health care grounded in science, at that time, the standard practice for regular physicians included bloodletting, purging, and the use of mercury and arsenic,9 which were more harmful than the herbal, homeopathic, manual methods, or other remedies that were criticized. Health care providers who did not practice in a regular way were banned from professional medical societies, which made it difficult for irregulars to practice health care as regulation and state licensing acts took effect as time progressed.5, 6, 10

In the introduction section of the 1847 AMA code of ethics, Bell et al8 writes, “Impressed with the nobleness of their vocation, as trustees of science and almoners of benevolence and charity, physicians should use unceasing vigilance to prevent the introduction into their body of those who have not been prepared by a suitably preparatory moral and intellectual training.” It was apparent that the medical profession recognized a responsibility to govern itself, to watch over the practice of health care, to protect the health of the public, and to prevent from practicing those they deemed unsuitable. For at least a century and a half, the medical profession unified and made concerted efforts to identify and eliminate irrational, unscientific, and unethical health care practices in the United States.

One may argue that if a group is to be recognized as a profession and hold cultural authority, then it must regulate itself rather than rely on another profession or external entity to perform this task.5, 11, 12 During most of the chiropractic profession's early growth, criticism of activities within the profession have tended to come from sources outside of the profession.13, 14, 15 If the chiropractic profession is to continue to improve, then greater self-regulation, self-reflection, and self-criticism are needed.13, 14, 15 One fundamental component of self-regulation is the ability of the members of a profession to critically review and appraise information, whether this information is from a peer-reviewed journal, a text book, a news report, an advertisement, an educational course, or a peer. Members of the chiropractic profession claim that chiropractic is based on science.13, 14, 15 Because it is expected that science-based health care providers engage in evidence-based practice skills,16, 17, 18, 19 we must also embrace critical appraisal activities.

Some may consider chiropractic an “unscientific cult,”20 which may also imply that chiropractors are not capable of thinking in a critical manner. I disagree. On a daily basis, and as an essential part of providing patient care, chiropractors search for and identify red flags (eg, signs or symptoms that suggest something is seriously wrong with the patient). Therefore, it should be natural for chiropractors to further develop skills that recognize the red flags in various other information sources. Figure 1 lists examples of common sense questions that help to identify red flags while reviewing new information or attending a seminar or other educational event.

Fig 1. Red flags to consider when evaluating information13, 19, 21, 22
Red flags to consider
Does the information source …
1. make unsupported statements or claims?
2. use outdated, inappropriate, or few references?
3. use references from only one source or primarily reference the author's works?
4. leave out essential references or information that may counter the author's viewpoint?
5. misrepresent or misquote references, making statements that do not accurately reflect the original source?
6. have a research design, purpose statement, or hypothesis that does not match the results and/or conclusions?
7. avoid declaring conflicts of interest?
8. have a financial investment in a product or service that the data appear to support?
9. receive funding from a company that is invested in a positive outcome?
10. claim that the study is “flawless” or diminish limitations to the study?
11. use inappropriate reporting and/or statistical methods?
12. include comments or opinions that do not relate to the purpose or findings of the study?
13. create new words or jargon for items or concepts that already have terms?
14. look at only one limited point of view and not other possible alternative explanations?
15. claim there is only one way to do something or one way to think?
16. state the same biased message over and over again?
17. use scare tactics or emotional statements to try to manipulate the reader?
18. use ridicule or mockery of other practices, professions, or scientific opinions?
19. focus only on the doctor, treatment technique, or making a profit instead of what may be best for the patient?
In addition to the above, red flags to consider when participating in seminars or educational setting.
Does the presenter …
1. make opinion statements as if they were fact?
2. over generalize, such as claim that if a smaller fact is true, then it must apply more broadly?
3. expect or request leaps of faith?
4. avoid answering questions directly?
5. become defensive when asked a question?
6. refuse to consider other theories that may differ than his/her own?
7. offer anecdotal evidence, a testimonial, or a case, then suggest the same must be true for all other situations or patients?
8. avoid undergoing peer review or expert scrutiny?
9. state he/she is an “expert” but is only recognized by select followers and/or not by other experts?
10. use questionable references for health care information such as postgraduate seminar notes, magazines, unpublished studies, etc?
11. use information from non–peer-reviewed or self-published sources (eg, personal Web site)?
12. state “references available upon request”?
13. charge for additional information if requested?
14. use the presentation to promote a personal, financial, or political agenda?
15. have a following only in his/her own circles, but not in scientific and professional circles?
16. have a background of scientific, legal, or ethical misconduct?

As consumers of scientific literature, we must remember that no information source or research study is perfect. When appraising information, we must weigh the good and the bad together and then decide what is valuable and worth using in our practices and for our patients. The presence of several red flags does not necessarily mean that all the information should be discarded because there may be some worthwhile information. However, in other instances, just one red flag may be enough to make a source completely unreliable or unusable. Each source must be critically reviewed on its own.17, 18 We also must remember that if something sounds too good to be true, it probably is.

I hope that most agree that each member of the profession has a responsibility to watch out for red flags when assessing information and then follow-up by taking the appropriate action. However, I suggest that we have an additional professional responsibility to fulfill. Each of us must avoid committing these errors (red flags) when we author an article, present information to others professionals, or discuss information with our patients. This duty is an integral part of our professional responsibilities to ourselves, our profession, and our patients.

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Conclusion 

Some entity should continue to keep a critical eye on chiropractic. However, that entity should be us, those who make up the chiropractic profession. It is time for our profession to move from external review to peer review and self-regulation. This means that each of us must fulfill this responsibility so that we need not rely on people or entities outside our profession. We need to heighten awareness of our ethical practices and denounce those within our profession who do not uphold professional and scientific standards. As Watkins22 aptly stated, “The position of chiropractic in our social order is of our own making. We are the only ones who can raise or lower it, and we must govern ourselves prudently if chiropractic is to develop and progress to its full possibilities as a science.” If we wish to continue as a profession, each of us must take the responsibility to think and act in a responsible manner. It is our responsibility as professionals to think critically, recognize red flags, weigh the findings, and then make the right decision in the best interest of our patients and the health of the public.

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References 

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  21. Green BN, Johnson AC, Adams AH. Caveat Emptor! Evaluate and maximize your technique seminar experience. Top Clin Chiropr. 1998;l5:19–26
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PII: S0161-4754(08)00254-6

doi:10.1016/j.jmpt.2008.10.001

Journal of Manipulative and Physiological Therapeutics
Volume 31, Issue 8 , Pages 559-561, October 2008

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