April 2006

The public perception of EBM

by Dr. David A. Jackson

Everyone involved in a health care profession seems to be well aware of the importance of evidence‑based research, guidelines and practice. But does the public understand what EBM (evidence‑based medicine) is, and does it care?

I think the answers to those questions are, in order, no...and yes.

No, the public doesn't yet understand exactly what is meant by the term "evidence‑based medicine," but it does care about the concepts behind it.

Although they can't be considered typical of the general population, the attitudes of a group of young medical students might reflect a similar perception among the public.

In a survey conducted last year of 963 students of medical, dentistry, nursing, pharmacy and public health departments in a medical university in Taiwan, less than one‑third said they had heard of the term "evidence‑based medicine" before filling in the questionnaire. Yet, more than two‑thirds agreed that it's important to learn the skill of searching medical articles in medical school and nearly 80% said they thought it's important to learn the skill of evaluating the quality of medical journals in medical school.

Chances are, if you asked the average layperson what "evidence‑based chiropractic care" is, you'd get a shrug or a blank stare. But if you asked that same layperson whether it's important for chiropractors to base their clinical decisions on the evidence found in published research, you'd get an emphatic "yes!"

It won't be long before the term evidence‑based care (or evidence‑based medicine) is as commonly used as "CAM" (complementary and alternative medicine) among the mainstream press and the public. It'll become the "in" word and the "hot" topic of the day. We'll be seeing more and more "EBM" publications and press releases from the medical and drug industry will emphasize that the products or services they're marketing are "evidence‑based."

Every health care profession will be jumping on the EBM bandwagon and making sure the public understands they are evidence‑based. Actually, we're already seeing this happen. The mental health industry, for example, has launched a new publication, Evidence‑Based Mental Health, the sister journal to Evidence‑Based Medicine and Evidence‑Based Nursing. One reason for the new magazine, says John Geddes, senior clinical research fellow of the Centre for Evidence Based Mental Health in Oxford is that "public perception of mental health services has not kept up with advances in research and practice (and) others have argued that mental health policy has usually been influenced more by political values than evidence."

Interestingly, Dr. Geddes adds that "we also need a culture change with better integration of patient values into the implementation of research and a need to go beyond professional rivalries and other barriers to provide the best available care for patients." He could well have been speaking about chiropractic.

It's generally agreed that the public will enthusiastically embrace the EBM concept, since it will help to eliminate some of the "political values" that determine what care they receive. It might also help overcome the perception (in most cases correct) that, as pointed out by Lee Newcomer, MD, senior vice president of health policy and strategy at United Healthcare in Minneapolis, in her opening remarks at an ECRI (formerly the Emergency Care Research Institute) annual technology assessment health policy conference, "consumers and physicians have lost their decision‑making ability and that someone else is controlling medical care decisions." Dr. Newcomer added that using "medical necessity" as a benchmark of appropriate care "will die due to market forces or legislation within 12 to 36 months."

What will take its place is evidence‑based decision making. "In the future, we believe that all doctors will be expected to provide evidence‑based justification of most medical interventions. The public will demand the evidence," states Todd Feinman, MD, chairman and president of Doctor Evidence, a company specializing in literature searches to locate medical outcome data about diagnostic tests and specific treatments.

This will be the case in chiropractic as well as medical offices. Patients will want to know why you are recommending adjustments to address their sinus problems, or to ward off their child's colds and the flu. They'll want to be able to see the research validating your care for their asthma or their hypertension. You'll need to give them references to the evidence that chiropractic works.

Right now, you'd be hard put to come up with research citations for anything but back and neck pain. And much of that research would be less than impressive.

The recent report in The Spine Journal, for instance, came to the conclusion that chiropractic "manipulation" was at least better than sham treatments. In essence, it's better than nothing. Yet, even that conclusion had a qualifier. "Manipulations may relieve acute back pain and sciatica with disc protrusion, although the results of subgroup analyses must be interpreted with caution," the researchers stated. Hardly a glowing recommendation. Is this the kind of research report you want to hand to a patient?

Or maybe you want to show them the much‑touted RAND Study, which chiropractors have used for more than a decade to "prove" chiropractic works. The problem is, the actual study merely concluded that manipulation was useful for acute low‑back pain in patients showing no sign of lower‑limb nerve root involvement. They recommended trying two different types of manipulation for two weeks each, and to discontinue therapy if there was no improvement.

Furthermore, the lead researcher, Dr. Paul Shekelle, later wrote an article to clarify the findings, stating, "RAND's studies were about spinal manipulation, not chiropractic, and dealt with appropriateness, which is a measure of net benefit and harms. Comparative efficacy of chiropractic and other treatments was not explicitly dealt with."

Of course, we can go back to the old (1979) New Zealand report, which is referenced on many chiropractic websites as "evidence" of chiropractic's effectiveness. But, when people look at the original document (also available on the Internet) they see that the actual report isn't quite as laudatory as many DCs would have them believe. In fact, the report actually disputes the idea that chiropractic care can address any "organic or visceral disorder" and says that patients should see a chiropractor only with a medical referral.

What about the Manga report of 1993? That, surely, is the type of evidence we can use in an evidence‑based practice, right? Wrong. First of all, the report focuses once more on manipulation for back pain and Dr. Shekelle later noted that "no one else has been able to come to those conclusions." Anyone looking online for information on the Manga report will easily find that quote along with the actual report.

The situation is actually quite dismal, as the British Medical Journal noted in July, 1998. After looking at 51 reviews of spinal manipulation for back pain, the BMJ report concluded: "We can only conclude that the effectiveness of chiropractic as a treatment for low back pain has not been established beyond reasonable doubt. ...On the basis of current evidence, it seems uncertain whether chiropractic does more good than harm." 

As a Canoe.com online article titled, "Scientific Studies and Chiropractors," by Paul Benedetti and Wayne MacPhail says: "In more than 100 years, chiropractic has been unable to demonstrate that its central tenet, that correcting spinal misalignments with manipulation is the key to wellness, is true. In fact, in a century, the profession has been unable to provide convincing evidence that chiropractic manipulation is even effective for uncomplicated, low‑back pain, the mainstay of its practitioners."

Obviously, in the future, being evidence‑based chiropractors is going to be imperative, but it will only be beneficial if we have the evidence to show that chiropractic has a positive, long‑lasting effect on health and wellness. Do you have any doubt that proper research, done scientifically and objectively, can provide the evidence for this? You and I have been seeing incredible real‑life results in our offices for years. More than a century of clinical experience indicates clearly what chiropractic can do for all people. Unfortunately, in today's climate, that experience is dismissed as anecdotal evidence, with little more authority than hearsay evidence in a criminal trial.

If you're like me, you know that chiropractic research can prove that chiropractic "works" and goes far beyond a medical treatment of back pain in adults. But that type of research isn't going to be done by people like Shekelle or medical researchers who have either tunnel vision when it comes to chiropractic, or a bias against any non‑medical approach (or both). We are the only ones who can produce that research, working together as a profession united in a single goal.

Our tasks are clear:

1) produce the evidence needed to prove the existence and impact of vertebral subluxation on human health and wellness; and

2) educate the public on the importance of evidence‑based chiropractic.

Only if we can do these two things can we hope to have the chiropractic paradigm compete with the medical model in the coming decades.

(Dr. David A. Jackson is chief executive officer of Research and Clinical Science ‑‑ RCS ‑‑ a private sector research program exploring issues of subluxation correction and chiropractic care as they relate to health and wellness. Previously, he served as president of the Chiropractic Leadership Alliance and Creating Wellness Alliance and was owner/operator of several private practice offices in California and Idaho that specialized in high‑volume, family wellness‑based care. For more information on RCS, call 800‑909‑1354 or 480‑303‑1694, or visit the RCS website at www.rcsprogram.com. Doctors of chiropractic may log on to a special limited‑access area of the site by using the username DC1 and password RESEARCH.)