March 2008

Fool me once, shame on you ... fool me twice, shame on me

by Dr. Christopher Kent

When the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) announced to the profession that they were going to develop "best practices" documents for the profession, they made a point of distancing themselves from previous guideline efforts. We were told that their "best practices" documents would be literature reviews that provide DCs with information. The CCGPP spokespersons were emphatic in stating that they would not be developing recommendations for number of visits, frequency and duration of care. Having lived through Mercy, I was skeptical. Despite my misgivings about the composition of the organization, I decided to give them the benefit of the doubt, and adopt a "wait and see" approach.

I didn't have to wait long.

They promised no visit numbers; now they're creating them. Their excuse is Worker's Comp in California. [1,2] Will their guidelines be evidence‑based? Nope. They will use a consensus process based on "ACOEM, ODG guidelines, CCGPP literature synthesis, CA WC Chronic Pain draft guideline, etc." and will "Develop seed statements concerning number of visits for acute and chronic LBP, outcomes and progress measures, etc." [3] Yep. They apparently plan to model the process of the very guidelines they call "draconian." I couldn't make this stuff up.

Furthermore, it is anticipated that these guidelines will quickly metastasize to other states. "We have been given a golden opportunity to complete this consensus process and influence the guidelines California (and the rest of the nation's) DCs will live with for years to come."

Dare we say that they are creating "Mercy II?" I predicted it. They are creating another "claim cutters bible." The same cliche that wafted through chiropractic meetings 16 years ago is being regurgitated today: "If we don't do it, others will." The fact is, whether a murder or suicide, the victim is just as dead.

A key factor in mitigating the adverse effects of the Mercy Guidelines was the uproar created by state associations when their members found their patients being denied reimbursement for care. To its credit, CCGPP learned from Mercy. They are now using COCSA to persuade member organizations to supply representatives to the consensus panel! We can only hope that the associations will not take the bait. Ayn Rand's concept of "the consent of the victims" comes to mind.

It has been said, "There is no right way to do a wrong thing." I find that substituting opinion for evidence, and using such opinion to deny patients care, is ethically, morally, and scientifically indefensible. CCGPP cannot transmute the dross of opinion into the gold of evidence through a consensus process. Patients deserve individualized care based upon objective assessments of function and quality‑of‑life, not a cookbook.

Perhaps Baruss [4] said it best: "If we are serious about coming to know something, then our research methods will have to be adapted to the nature of the phenomenon that we are trying to understand...One may need to draw on the totality of one's experience and not just on that subset that consists of observations made through the process of traditional scientific discovery."

Consensus isn't scientific discovery. It's opinion cloaked in the very thin veneer of process. Let's not get fooled again.

References

1. Letter from CCGPP chairman Mark D. Dehen, DC to Jerry DeGrado, DC, chairman of the Congress of Chiropractic State Associations (COCSA). January 17, 2008.

2. e‑mail from COCSA dated January 18, 2008.

3. "CCGPP Takes on Workers' Compensation Guidelines in California." Dynamic Chiropractic. January 28, 2008.

4. Baruss I: "Authentic Knowing. The Convergence of Science and Spiritual Aspiration." Purdue University Press. West Lafayette, IN. 1996, pp 40 41.

(Dr. Christopher Kent, president of the Council on Chiropractic Practice, is a 1973 graduate of Palmer College of Chiropractic. The WCA's "Chiropractic Researcher of the Year" in 1994, and recipient of that honor from the ICA in 1991, he was also named ICA "Chiropractor of the Year" in 1998. He is director of research and a co founder of Chiropractic Leadership Alliance. An attorney as well as a chiropractor, Dr. Kent is a member of the California bar. With Dr. Patrick Gentempo, Jr., Dr. Kent produces a monthly audio series, "On Purpose," covering current events in science, politics and philosophy of vital interest to the practicing chiropractor. For subscription information call 800‑892‑6463.)