Talk:Chiropractic/Archive 2

Chiropractic

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The history seems mixed in with the presentation of the theory, which to some extent is unavoidable, but it seems odd to discuss the concept of subluxation _after_ the legal fight with the AMA. DavidGoodman 21:52, 2 November 2006 (CST)

I've re-ordered. I think this is basically a good aricle, and that the historical approach is a good way to explain the subject, I've trimmed it down from the WP original, and thrown some detail into the references. I'm now done with thisGareth Leng 11:06, 7 November 2006 (CST)

APPROVED Version 1.0

Discussion for Version 1.0 stopped here. Please continue further discussion under this break.

Image is a copyright violation

That image was lifted from this website. The summary of the photo prettymuch freely admits it was just lifted from a Google Image search. This is a huge no-no, no? Benjamin Lowe 16:40, 14 February 2007 (CST)

Agreed, it has to go. Chris Day (Talk) 16:50, 14 February 2007 (CST)

I'll check into getting it removed properly. Matt Innis (Talk) 22:05, 14 February 2007 (CST)

Rationale for replacement of acronyms and informal abbreviations.

This references recent changes to whole article, where acronyms and abbreviations (DC, MD, GP) were replaced. As I see it, the use of these detracts from the literary quality of the article. These are informal and colloquial terms. They are used, as far as I know, only in North America, and to an outsider seems inappropriate to formal, quality writing which is intended for all of the English speaking world. Do the European and British chiropractors have the degree DC? In South Africa they are awarded a Master in Chiropractic degree, after a tough and long course, and are quite entitled to be called "Dr", but I am not aware of them calling themselves "Dee-sees":) In the UK and Commonwealth countries, Doctors definitely are not MDs (that, over here, is a far higher degree in medicine). After the changes, one has to check that the writing still flows properly, since changing the length of words may make parts "sound odd". I have not noticed any such. --Christo Muller (Talk) 09:01, 20 February 2007 (CST)

Hey Christo. I think we go back and forth on this one. See Chiropractic education for the education questions. I think the problem comes more with what to call MD's and that causes us to use DC's to qualify the difference. I haven't seen your solution yet, but let me check. Matt Innis (Talk) 09:31, 20 February 2007 (CST)

Ah, yes, I see you used physician for MD. I know in some US states, chiropractors are also be called physicians (mine included). The distinction there is medical physician vs chiropractic physician. I'm okay with it. For accuracy sake, I don't think either is a problem (Dc vs chiropractor) so if you think it flows better, that is fine with me. Matt Innis (Talk) 09:41, 20 February 2007 (CST)

Hi Christo, personally I'd always prefer to avoid abbreviations as I think they often get in the way of understanding, so I'm with you 100% on this issue alone, and of course you're also right about MDs. Gareth Leng 11:23, 20 February 2007 (CST)

AMA section

As per a request by Larry for us to review and rethink the section on the AMA plans], I think we have the choice of either totally eliminating the section or editing it to a more neutral tone. How about everyone take a shot at it and lets see if we can get something that we can all re-approve. Thanks, Matt Innis (Talk) 19:13, 4 March 2007 (CST)

I think that it should be rewritten from a neutral perspective. The way it is now, it's from a "neutral" chiropractic prespective. I don't know the history well enough, I have to do some research, but I think, overall-that the facts that are important to present are that the AMA, and Medicne, generally, after being reformed (at least in America) by the Flexnor report, zealously attempted to eradicate association with [practices outside the health sciences,that during that period (up to 19XX), there was an understanding within the medical profession that referral to chiropracters or willingness to teach in schools of chiropractic was unprofessional (I'm writing this off the top of my head and that might not be the right word) for an MD (this is the US so I think MD is ok) and that there was a lawsuit that forced acceptance of chiropractic as a legitimate healing art. Meanwhile, the culture within Medicine changed over the last decades of the 20th Century such that, with a recognition of increasing public interest and satisfaction in alternative medicine (or whatever we call it-CAM) that a more open minded evaluation of these practices by physicians was in the best interest of patients. At the same time, with he advent of evidence -based medicine, it became more clear that "scientific efficacy" (again, the words here are preliminary) was not evident for many practices that were basic within the health sciences, and younger generations of physicians were more tolerant towards practitioners of healing arts that lay outside the health sciences, at least to the point of being willing to discuss patient care, and be interested in evidence based evaluations of CAM. The way that this history is presented in the article is very much from the restriction of trade/battle over patient fees perspective. I think that view is the problem, as well as some of the words-like propaganda. This may come from the focus on the lawsuit- but the lawsuit, although important to include, is really not the main story. I think the changing view of CAM and the direct basis of Science in Medicine is the bigger part. Further, I don't know anything about the relationship of Medicine and Chiropractic in the rest of the world. That seems to be important to art least mention.Perhaps we can just delete the section for now-do a quick approval without it- and then over the next few days write a balanced less polemical view, and stick it in a third approved edition.Nancy Sculerati MD 21:36, 4 March 2007 (CST)

Webster Merriam defines propaganda as: 2 : the spreading of ideas, information, or rumor for the purpose of helping or injuring an institution, a cause, or a person 3 : ideas, facts, or allegations spread deliberately to further one's cause or to damage an opposing cause; also : a public action having such an effect

The judge's opinion in the Wilk case makes it clear that the antichiropractic literature circulated by the AMA was exactly this. I don't really see the problem? The section, on my reading at least, was wholly neutral. I've reworded it, but I don't really see how it can be expressed very differently and still be in accord with the facts of the judicial opinion.

The Wilk case was a very clear turning point, and I don't know how any encyclopedic article can avoid this. It is true that the public interest defence offered by the AMA isn't described here, it was rejected by the judge and was apparently conceded by the AMA during the trial as no longer valid as a justification for continuing the boycott, so it's hard to see how to introduce this.

The AMA during the trial accepted that there had been considerable improvement in chiropractic, and they claimed that this was a positive outcome of the boycott.

It is tricky. The AMA's actions were clearly regarded as thoroughly reprehensible by the judge in this case. Both the chiropractic profession and the AMA itself regard the activities that were identified as unlawful restraint of trade as of central importance to the evolution of chiropractic. How can any balanced article neglect this?

Gareth Leng 07:06, 5 March 2007 (CST)

I agree with both of you. I think the ages old turf battle in the early 1900s was a contentious battle, but with the advent of evidence based medicine concepts, the efficacy of chiropractic and at least spinal manipulation was becoming evident as being at least as efficacious in some cases as some other medical interventions, but there were those on both sides that were just unwilling to give up the fight. At the same time as "younger" and "less committed" doctors were beginning to see that there may be some value here, AMA ethics guidelines still made it unethical to associate, refer to, accept referrals from, or teach in chiropractic colleges - not to mention research anything related to chiropractic. The Wilk suit broke this barrier and allowed more corroberative efforts to emerge. I'm not sure this would have happened had the case not broken through this barrier so that people like Nancy and I could now even consider talking to each other about these issues. If we could write a subsection explaining this evolution such as Nancy suggests, maybe that could solve our problem. What do you think? -Matt Innis (Talk) 07:33, 5 March 2007 (CST)

What Nancy proposes is fine by me, but I'm not sure that it really fixes the problem, if indeed there really is a problem. In the UK, medical students are now taught of the overriding importance of the patient-doctor relationship, to recognise and appreciate that this an area in which the traditional practise of conventional medicine has much to learn from some CAMs. However it seems to me that Nancy's suggestion fits better into a lead overview of the Healing Arts rather than specifically chiropractic.

What the AMA and the NHS say now is very different from what it is sometimes presumed that they "really think". I don't think that we can address the latter. I think we must respect what is said publicly. To undermine the written word by insinuation is just wrong in my view. If it is the case that the AMA still thinks that chiropractic is reprehensible but say differently for legal or political reasons, then I'm afraid they must be hung by their words; it's not up to us to damn them for spinelessness, nor is it ours to see the feelings behind the words. I don't think we've tempered in the article what the AMA said about chiropractic in 1966, nor should we; nor should we temper what the courts said about the AMA, nor should we disguise the fact that the AMA retracted from their position - and indeed had done so before the end of the court case. The judge issued an injunction against the AMA, because she did not believe that the AMA were sincere in what they said... so where is neutrality here? We report, we don't comment; we do not attribute motives to what is said or done, but surely we must report the judicial opinion accurately. Gareth Leng 08:26, 5 March 2007 (CST)

Are we satisfied that we have stated the facts neutrally? I agree with all the changes made so far. It may also be apparent that the views of the AMA (or ACA for that matter) are not always the views of its members as well as the fact that not all MDs in the US are members of the AMA. I would even go as far as to say that the hard line held by the AMA in the 1960s may well have led to a loss of membership during those years. Membership has improved, whether the result of softening on these issues is debatable. --Matt Innis (Talk) 10:04, 5 March 2007 (CST)

Have we staed facts and reported opinions objectively? I really can't see that there is anything in the AMA section that is objectively problematical. Reading the judge's opinion, it's hard to see how we could report the case any differently and still be objective.Clearly we need to cite that opinion in full, the link I found is to chiro.org; there may be a direct link which would be better.Gareth Leng 10:24, 5 March 2007 (CST)

I don't think the link makes that big a difference. I will put the re-approve tag on it and give it a day to think about it. -Matt Innis (Talk) 10:31, 5 March 2007 (CST)

I made changes in severaql places-please go over todays "recent changes" to see and check. Nancy Sculerati MD 12:10, 5 March 2007 (CST)

Thank you Nancy! Well done as usual. I think we could tighten all of the AMA stuff a little, just to keep it from overwhelming the rest of the article. I would add more to the rest, but we are once again going over. -Matt Innis (Talk) 13:43, 5 March 2007 (CST)

Nancy, the section on 19th century standards that you added was there before, but we took it out when we moved the history section. Obviously, I too, think it is important, as did Gareth when I first wrote it, but we took it out due to length. Perhaps we need to go ahead and put it back in. Again, though, we seem to be delving off on a tangent that could lead us away from the purpose of this particular article. Maybe we should shorten it all and build the Chiropractic History article instead. - Matt Innis (Talk) 15:11, 5 March 2007 (CST)

I really think we should keep it in, here why: when a user, at least from the States, who has heard about chiropractic but doesn't know much about it reads this article it is important that they understand the relationship between Medicine and Chiropractic. Like that kooky e-mail Larry got, many people have some notion that "doctors are against chiropractic", and further-without explaining some of the background of educational systems for 19th/20th Century health profesionals, which leads into how DD Palmer ran his school (it was really, in length and breadth not much different than the bulk of the proprietary medical schools), which leads into how, after the Flexner report, in one sense the schools of chiropractic were a recidivist branch that the AMA couldn't touch, with gives a balanced view of why professors of medicine might have spurned chiropractic, as well as the financial aspect, and finally-mentioning the lawsuit shows how there was a seachange in relations between medicine and chiropractic that was legally mandated. Without that the reader is left without any good understanding of these major points. I think this is more important than many other sections of the article. Nancy Sculerati MD 15:41, 5 March 2007 (CST)

I agree with your outline and purpose, so I think we are on the same page. I think we can do it, but we may have to re-arrange somewhat because I think we are repeating ourselves some. So maybe if we get it into chronological order, we can simplify it some. I am a believer in context. If we put everything into context, suddenly the picture is much clearer and the reader can understand not only what it is, but why it is as well. I also changed the date to the 14th on the ToApprove template. Lets do this right;) --Matt Innis (Talk) 15:51, 5 March 2007 (CST)

Flexner Report

Hey All, one thing I have been noticing is the tendency for this article to drift to into a postion that the Flexner report directly influenced chiropractic. My research does not support this contention. At the turn of the century, a large percentage of physicians were still using homeopathic type remedies but the schools were so disorganized that these were the direct target of the Flexnor report. At the time of the report there were only 3 or 4 chiorpractic schools (at te most). And remember, the list was made at least 6 years before, when the only "drugless" schools would have been Palmer's and Still's osteopathic schools. Palmer had about 21 graduates before he was arrested in 1904. Several of those were MDs (they are not sure of how many). My point being that the Flexnor report was directed mostly at the homeopathic schools. The significance of the flexnor report is that once the homeopathic schools were closed, where did those physicians go? But I am only guessing on that:) Matt Innis (Talk) 19:14, 5 March 2007 (CST)

The Flexner report was directed at all schools, including many that were allopathic. It was directed at any school that allowed students to study without strict academic prerequisites, that did not offer laboratory training in science, and that did not require students to show proficiency on tests on evaluations on at least a university level before graduation. It had nothing much to do with anything else. I think that the Flexnor report really did influence chiropractic, because after that time there was a much more complrte schism between college educated people entering medical schools and then having formal postgraduate clinical training (eventually- those changes took decades), based on the John Hopkins model, and chiropracter schools being in a whole different category. I have begun to read the history of those times as far as the history of health care in the United States and the Flexner report-which was the culmination of several decades of a movement that was involved within Medicine and civil-minded people of increasing regulation of public health with creation of oversight boards, and setting standards for certification of health professionals as well as medical education, marked. in 1910, a change. Most of the many schools of medicine closed, all of the small proprietary schools closed, including, arguably, some that actually offerred good education. That included at least one of the black medical schools in Kentucky (look at the stub just started Flexner Report discussion for reference. Again, the purpose of an encyclopedia article on chiropractic is to give a complete view of the field, especially since it was invented in the US, and the schism between MDs and Dcs was so pronounced, all of this is important. How many chiropractic schools existed before the Flexnor report came out is not the point, the point is that before the Flexner report reforms, the average chiropracter, from whatever school, was not so different in backgound and education as the average MD- at least in most rural communities in the US. After the Flexner reforms, only the better educated MDs came to be eventually regarded as legitimate physicians. Of course, there was a transition period when physicians from the old proprietary schools were still practicing and grandfathered in, but the academic university trained MD of the 1930's etc saw them as "quacks" and prejudice was not confined to homeopathy or chiropracty. Some of it may have been professional jealusy over patient fees, but plenty of it was well educated physicians who were appalled at the fact that some practitioners had no understanding of te germ theory of disease, vaccinations, public health measures, and encouraged their patients in traditional health beliefs that predated modern medicine. The way the article read in its first approved version, it presented the AMA strictly as a business organization bent on stamping out a commercial rival.The AMA does have an element of being a business organization, and that is certainly why Chiropractic won the law suit. But the AMA, especially in 1910, is and was far more than a trade organization, it has always had a major purpose in improving medical care in the United States and in promoting a high standard of education and quality within Medicine. That absolutely must be made clear, because that's the fair view.Nancy Sculerati MD 09:45, 6 March 2007 (CST)

empiric medicine

Nancy made a sentence that needs more explanation:

• Although many clinical practices in medicine were based on empiric teaching rather than science, other empiric sorts of practices, like chiropractic, were disdained as meritless by the majority of MDs.

This is very true and begs a "why?" Why would there be a double standard? I'm thinking this is because of the attitude of the Palmers toward medicine and the environment of paranoia or mistrust. Any other ideas that we might be able to verify as good reasons. I think DCs would like to think it was all political, but I doubt it was. --Matt Innis (Talk) 20:09, 5 March 2007 (CST)

I don't know; I think that although medicine was very extensively (mainly) based on empirical practice, it aspired to develop in a way that was led by basic biological understanding. BJ Palmer also aspired to make chiropractic scientific, but his concept was subtly different, he saw science as a way of providing a rational basis for given chiropractic practics. In other words, I think the difference is that in conventional medicine, there wasn't an overt "attachment" to any particular form of treatment. So I think the disdain came because conventional medics thought that the scientific basis for chiropractic as advanced by Palmer was tainted by the intention that it should justify the particular practices of chiropractic. I don't know if I've explained this well, and don't know if I've got it right. So on Nancy's sentence, I don't know if it was the practice of chiropractic that was regarded as meritless or the scientific foundations that were disdained, and suspect that the disdain was because the explanations were seen as justifications, rather than as objective accounts based on science as it was understood. Gareth Leng 03:48, 6 March 2007 (CST)

At present, the article describes the AMA position on the merits of chiropractic before the Wilk case, and reports the case as an antitrust case won by Wilk et al. This makes a very serious omission of balancing fact, that the judge declared in very clear terms that the campaign against chiropractic was dishonest as well as unlawful, and indeed this was the basis on which she issued an injunction against the AMA. Presenting the AMA case against chiropractic but not stating that the judge found this case to have been dishonestly presented is just wrong in my view.Gareth Leng 10:29, 6 March 2007 (CST)

The AMA

Hi, Nancy. The role of the AMA in furthering medical eduction has always led this section, so I didn't read it as being as negative as you did.

However I think that your changes have removed part of the record that is necessary to understand the hostility between Chiropractic and the AMA. The following sections are directly in the court record; they are not our opinion or interpretation, but the judge's summary. Certainly it casts the AMA's actions in this case in a bad light, and this is properly tempered by explaining the remedial actions of the AMA since. But the record does appear to show that the AMA's actions went far beyond what is fair and reasonable; I think looking at the record, the excesses are those of the Committee and that by the time of the trial the AMA leadership was desperately distancing itself from them. Below is the section that was removed:

"Judge Susan Getzendanner said that, according to the evidence:

"the defendants took active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractors, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country." [13] The judge reported that the Committee on Quackery essentially consisted of doctors who had volunteered for service on the Committee because of their firm belief that chiropractic had to be stopped or eliminated. Evidence had been given to the Committee that chiropractic was effective - more effective than the medical profession in treating certain kinds of problems, and that some medical physicians believed chiropractic to be effective, and that chiropractors were better trained to deal with musculoskeletal problems than most medical physicians. However, the Committee did not follow up any of these studies or opinions. At the trial however, most of the witnesses who appeared on behalf of the AMA agreed that some chiropractic treatment is efficacious. "

The reference gives the complete published judgement, and all of the details in the above are in that judgement.Gareth Leng 10:21, 6 March 2007 (CST)

I only removed it- as I wrote (I hope) in that Summary section that you make notes in when you make changes, because I though it could go into the History of Chiropractic. I'm happy to leave it- but I think that we should agree (probably one way or another) to up our limit to 40 kB for this article. At the time I culled that quote, I was looking for stuff to move or drop, and I really think that the long section on what goes on in a "typical" chiropractic office should stay. I deleted some of the subluxation stuff because now there is another article, but -although this article might be improved with some rewriting, I think that dropping it down to 32 kb will ruin it. Nancy Sculerati MD 10:41, 6 March 2007 (CST)

Thanks, I agree on the limit; think it could be copy edited to tighten, let's see after that.Gareth Leng 12:01, 6 March 2007 (CST)

What most MDs think or thought... I always have problems with such statements mainly because when I try to find evidence it is often ambiguous or contradictory. I came across this for example, from 1989 (the Wilk era), and it doesn't really support a general negative view of chiropractic Cherkin D et al (1989) Family physicians' views of chiropractors: hostile or hospitable? Am J Public Health. 79:636–7 [1]. Similarly survays of collaboration generally show a degree of openness from MDs that is just not consistent with a general negative view. Is there a difference between family practitioners, who might be sympathetic to empirical practise, and academic or hospital based medicine I wonder?Gareth Leng 12:37, 6 March 2007 (CST)

OK, 40kB and I don't think I've lost anything...Gareth Leng 12:50, 6 March 2007 (CST)

There certainly was in the US. There is a book (I think from the 30's) called Arrowsmith by Sinclair Lewis that is fiction, but a classic of medical fiction. It tells the story of a University trained young doctor setting up practice in the midwest and having to struggle to accept that the established MD's in town are nearly totally ignorant of science and yet nearly worshippped by their patients, who flock to treatments like electrical and magnetic fields, while he is held in ridicule. He knows how to give diptheria toxin, unlike them, but the child dies anyway and it is them that know the "art" of medicine, how to smooth things over with the parents. He ends up working on medical research, goes back to the lab.However, I think that as time went on, although people trusted their local doctors, regardless of education, all practicing MDs from the US were products of the reformed medical schools, and more and more credence was given to the standards set by academic medicine. Remember, in the US, by the 1970's there were few "family physicians", there were so-called GPs who were on the low end of the staus hierarchy, and lots of specialists. That began to turn around in the late 80's and 90's with formal residency traing -for the first time-in family medicine. When I was in medical school in NYC (class 1981) referring doctors from outside of academia were called LMD's (an abbreviation for local medical doctor) and it was generaly understood among the residents and attendings that you never trusted a LMD, a few of them might be good, clinically, but they were out of date and their tests and work-ups had to be repeated for the sake of the patient. "Most MDs" is no fabulous way of putting this, but in America, especially durring those years, there great public respect for the "top doctors" and the top doctors were at the big medical centers, and the big medical centers were directly affiliated with Medical Schools, that were mostly affiliated with Universities. In the 1970's-90's there was a movement in the US against Medicine, the health care system was bankrupting families while the salries of physicians skyrocketted, and -although science brought many good things, still the art of healing, which actually comforts patients, was notably lacking in most if not all of the big academic centers. Also- as actual trials and tests of long held medical practices came to pass, many things that were taken for granted as "scientific" and "correct", like shaving pubic air and painting the birth canal area with antiseptics in women for birth, turned out to either make no difference or to be actually harmful. Then managed care came in to reduce costs and the academic medical centers began giving courses on bedside manner -for lack of a better word. As in the US physicians have to cover their own malpractice costs and many other expenses, like rent,-which all continued to rise as managed care continually reduced fees, many physicians began to look at cosmetic procedures and products, and alternative therapies as a way to survive financially because these products and services (I'm not saying chiropractic, but many of them) are not regulated to a few dollars a visit. Additionally, most of the alternative medicine practices were performed in ways that were fairly uniformly high in the "bedside manner" department, since much depended on placebo effect and that is quite dependent on presentation to the patient. So, suddenly, between everything, alternative medicine got some respect. That's very abbreviated, but I think -overall-true. Nancy Sculerati MD 14:49, 6 March 2007 (CST)

A little JAMA research

I'm going through the full text articles that I can access online from JAMA (the Journal of the American Medical Association) that come up with a search for keyword: Chiropractic. As is my usual wont, I'll stick the references below with my own one or two line summary.

Chiropractic CONDEMNED JAMA, Apr 1969; 208: 352. This rapidly got out of hand, lots of articles and I found myself reading additional journal article linked to full text in reference section. Suffice to say- the late 60's and 70's were full of articles like the one referenced before this statement. Then there began to be articles that looked at controlled trials of chiropractic therapies, then some articles on the inclusion of alternative medicine courses in medical schools. Those articles were the subject of many letters, ranging from a co-plaitiff of Wilks applauding the JAMA for recognizing the worth of chiropractic, to articles from physicians condemning quackery. Many letters pointed out that just because medical schools had courses on CAM, that did not mean they were "how to do it" courses, but likely informational courses. The authors of one paper on courses replied, condemning the letter writer who used the word quackery. There was a link to a New England Jounal of Medicine article that surveyed patients and found 42% used alternative therapy and did not tell their physicians. All in all, the tone definately changes - from let's condemn the quacks to this is something our patients use, let's know more about it. If you like, I can send you some notes I made in a word document. Nancy Sculerati MD 16:59, 6 March 2007 (CST)

That is my understanding as well. That pretty much mirrors our article in the sequence of the scientific reform of chiropractic in the Chiropractic History article. We are not far apart. --Matt Innis (Talk) 19:04, 6 March 2007 (CST)

Overall changes

I don't see that we are changing the article in any significant way that I would consider an improvement worth approving over the original one. It seems that the more we rewrite the more we go in circles. I am concerned that what started as changing the word "propaganda" to make the AMA look better has lost its neutrality. -Matt Innis (Talk) 12:01, 7 March 2007 (CST)

Yes, comparing the present version with the approved, it looks as if the present draft has gone walkabout (we trust it comes back more clear-headed:)). The original idea was to reduce the section on the AMA. (Incidentally, the Am Coll of Surgeons had in 1987 already said that it approved of cooperation between surgeons and chiropractors, so the AMA was not the only player).

I've reduced the original AMA section as :

<Book reference>

In 1963 the American Medical Association formed a Committee on Quackery, which campaigned actively against the practice of Chiropractic. Efforts were made to ensure that Medicare should not cover chiropractic, that the U.S. Office of Education should not recognize a chiropractic accrediting agency, that the two national associations (AMA and ACA) should remain separate, and that state medical societies should initiate legislation to control chiropractic. The AMA distributed anti-chiropractic literature to teachers and guidance counsellors, caused 'Chiropractic' to be removed from the Health Careers Guidebook of the U.S Department of Labor, and established guidelines for training in medical schools about the hazards of chiropractic. In 1966 the AMA declared that "chiropractic is an unscientific cult whose practitioners... constitute a hazard to healthcare in the United States."

As a result of these measures, Chicago chiropractor Chester Wilk and three others brought an antitrust suit against the AMA (Wilk et al vs AMA et al) in 1976. They claimed that the AMA was in violation of the Sherman Antitrust Act by engaging in a conspiracy to restraint of trade. In 1987 the Federal Appeals Court in found that, while accepting that the AMA had a duty to show its concern for patients, it was not persuaded that this duty could not have been done in a way that was less restrictive of competition, for instance by public education campaigns. Since the case was not about the scientific basis of chiropractic treatment, the court declined make any decision on that issue.

Subsequently (1992ref) the AMA has declared that "It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient.” It is acceptable to the AMA that physicians teach in recognized schools of chiropractic. This has opened the doors for AMA members to collaborate more openly with chiropractors in patient care, teaching and research.

Some additional ideas / random thoughts: More important to me is: This is a summary of chiropractic, and the history can be expanded a History of Chiropractic. The Wilk/AMA case deserves its own article. We are not told here what happened to chiropractic between 1910 and 1960. It may be easier to balance the history by splitting the history of chiropractic into decades, and state what ever was of note, then decide how to balance the time line. How was chiropractic developed, taught, promoted? what are the main negative/positive points per decade (there are 11 to cover)? I can't see how a discussion of the 19th century could fit in with the history of chiropractic, except for DD. I ask myself: Where did the recognition of chiropractic come from, if there was all this opposition all the time? Is there place for some more international perspective?

--Christo Muller (Talk) 15:33, 7 March 2007 (CST)

Hey Christo! That works, too. But, if we are going to add the sentence on the judge not ruling on the scientific validity above, we probably should mention that the judge said that the AMA suppressed research. Also, did you see Chiropractic History. This was originally in this article, but gets cut out and then it seems to grow again:) Like a salamander;) -Matt Innis (Talk) 17:27, 7 March 2007 (CST)

I agree that the Wilk case needs its own article. Assuming that we agree to take the long version and swiftly approve it as a short article in its own right, we'd have to consider what aspects are essential for this article, and this goes to the key issue of why the case was so important. I think it is an essential part of understanding the antipathy between conventional medicine in the USA and the chiropractic profession. I think the essential elements are these

• 1) the AMA had actively tried to suppress chiropractic, arguing that its basis was unscientific, and that it deflected its patients from seeking what it saw as more appropriate care.
• 2) the chiropractic profession interpreted the AMA campaign as an unscrupulous attempt by one business competitor to unfairly suppress a rival
• 3) four chiropractors took the AMA and others to court on this basis, even though by this time the AMA had lifted its boycott on members working with chiropractors
• 4) after a long series of court cases, the judge agreed with the chiropractors that a) the AMA had indeed been unlawfully suppressing a rival, b) the AMA had suppressed evidence for the efficacy of chiropractic and c) most of the witnesses at the trial that were called by the AMA had agreed that chiropractic was efficacious in some circumstances
• 5) the judge also agreed that some (but not all) aspects of chiropractic had no firm scientific basis and that the AMA were entitled to be concerned about patient safety, but stated that this could and should have been done in ways that were not unlawful or unfair
• 6) the judge was not persuaded that the AMA was sincere in declaring that it had already changed its policy on chiropractic before the trial, so issued an injunction against the AMA and obliged the AMA to publish her judgement in full in American Medical News

I believe these to be the facts, and that they are essential to understanding a) the depth of antipathy between the AMA and chiropractic and b) the continuing distrust of the AMA by many in the chiropractic profession. I believe also that there are some very common misconceptions that should be corrected:

• a) that the AMA "backed down" - no, it did not back down, it fought to the very end and lost.
• b) that the case was purely about trust law - no, the injunction was placed because of the dishonest nature of the AMA campaign,
• c) that efficacy was not an issue - no, efficacy was central to the evidence in the case; the judge declined to declare chiropractic efficacious or not, but reported that the evidence given at the trial favoured a conclusion that it was efficacious;
• d) that scientific basis was not an issue - no, this was the central tenet of the AMA defence. The judge concluded that the AMA case had some merit in that some aspects of chiropractic had a weak scientific basis, but said that this was not true of all aspects, and so dismissed the AMA defence.

I have to agree with Matt that if the allegations by the AMA about chiropractic are reported, then so must be the judge's dismissal of those allegations as coming from a Committee comprised of doctors who had volunteered for the Committee because of their preformed disapproval of chiropractic, and who ignored all evidence and opinions given to them that favoured chiropractic, including evidence and opinions of other physicians.Gareth Leng 08:39, 8 March 2007 (CST)

I'd suggest the following abbreviated account for the present article:

In 1963, the AMA formed a 'Committee on Quackery' that began a campaign to eliminate chiropractic, and the AMA set out to forbid its members from working with chiropractors on the basis of the AMA 'Principles of Medical Ethics'. Until 1980, these stated that "A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily professionally associate with anyone who violates this principle." As a result, in 1976, a Chicago chiropractor, Chester Wilk, and three others brought an antitrust suit against the AMA (see Wilk et al vs AMA et al.). In 1987, the Federal Appeals Court found the AMA guilty of conspiracy and restraint of trade. The AMA lost its appeal to the Supreme Court.

In her judgement, (ref) Judge Susan Getzendanner strongly criticised the AMA campaign, saying that the AMA had taken: "active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractors, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country." [13] She described the Committee on Quackery as essentially comprising doctors who had volunteered to serve because of their belief that chiropractic should be eliminated. Evidence was given to the Committee that chiropractic was more effective than the medical profession for certain problems, and that some medical physicians believed that chiropractors were better trained to deal with musculoskeletal problems than most medical physicians. However, the Committee did not follow up any of these studies or opinions. At the trial, most witnesses who appeared on behalf of the AMA agreed that some chiropractic treatment is efficacious. The court recognized that some chiropractic practices lacked a scientific basis, and that the AMA had a duty to show its concern for patients, but was not persuaded that this could not have been achieved in a way that was less restrictive of competition, for instance by public education campaigns.

In 1992.... Gareth Leng 09:07, 8 March 2007 (CST)

To see the difference

This is the difference between Christo's version and Gareth's version [2]

Folks, take a good look at them both and surely this is an editorial decision as to the direction we want to go. This being an article on my profession, I don't feel comfortable making this call, but trust your combined integrities to make a call that is best for the project. -Matt Innis (Talk) 11:14, 8 March 2007 (CST)

Minor query - Nancy, your edit summarised as "this is just true- it's the health sciences not just "conventional physicians" - were you thinking of osteopaths here?Gareth Leng 11:16, 9 March 2007 (CST)

No, I mean the allied health sciences: nurses, physical therapists, physician's assistants, radiology technologists, medical technologists. I love Matt, and I don't want to personally offend him, but it is important that it is clear that chiropracters are not just a sort of unconventional doctor. The chiropractic understanding of disease is completely apart from the common biological understanding of disease that all the allied health sciences are taught. In the US, there are a few OD's, and I don't know that much about them, but basically, ,any take residency training like MDs and their practice is indistinguishable for those in the mainstream. One thing we are really lacking here is on the practice of chiropractic in the rest of the world. What are the educational requirements? What is the profession like elsewhere? It may be more integrated in with the health scieces, here it is really completely separate. Nancy Sculerati MD 11:45, 9 March 2007 (CST)

The chiropractic understanding of disease is completely apart from the common biological understanding of disease that all the allied health sciences are taught.

I took my undergraduate courses at Indiana University majoring in biology alongside all the premed students. The course completed as a BS in human biology through Logan College of Chiropractic. The Chiropractic program at Logan included Organic Chemistry and Biochemistry taught by a PhD in Biochemistry, Microbiology by a PhD in Microbiology, Dermatology by a Phd in Dermatology. Human anatomy included 8 months of human dissection. And others.. though we did not have any instruction in pharmacology. I have no doubt the residency programs for medicine are quite extensive as they need be in order treat the many life saving illnesses that you treat, as our internship spends most of it's time treating more of the chronic degenerative type conditions, but I am quite sure we have pretty much the same understanding of disease that all allied health sciences are taught. I think we might be taught things from a more vitalistic approach, with the understanding that we aren't so much supposed to change the bodies response to disease as much as assist it in responding to disease. Obviously, there are disease conditions that are more viral than the human organism and for those we need to be constantly vigilant so we can get them to those equipped to battle them. But that is not any different than any other allied health care field's understanding, I don't think for sure, but obviously you don't know what you don't know. --Matt Innis (Talk) 13:57, 9 March 2007 (CST)

This is an interesting thread, though I'm not sure where it's going. obviously I teach in a Medical School. In the UK generally the medical curriculum has evolved to become very vocationally oriented and practically based, so on the face of it Matt's education appears to have a much stronger basic science component than current UK medical training. Indeed medical students are "taught" very little basic science of any sort, depending on what you mean by taught. A medical degree here is a primary degree, not a postgraduate degree, and students enter at 18. Their education (5 years) is based around problem-based learning or case-based learning supplemented by skills training from the very beginning. Problem-based learning is student led in small groups working around a theme (a hypothetical scenario) with a facilitator to ensure that the students keep roughly to learning objectives. Basic science therforeis not taught in a structured way at all, but arises incidentally. This system of teaching has its fans and its critics, and I am a bit of both. Many of my colleagues feel strongly that current medical training does not impart a coherent understanding of scientific foundations of medicine. However the emphasis on skills, independent continuing learning, and on the patient-doctor relationship, are clear benefits. Chiropractic is small here, but there are undergraduate and postgraduate degree courses in colleges that are associated institutions of some of the new Universities; these Institutions are often "looked down on" by Institutions such as mine as they are generally mainly teaching Institutions with little academic research delivering mainly vocational rather than academic courses, but they often have a good (sometimes better) reputation for teaching quality. I,ll try to find about the curriclum. Gareth Leng 05:24, 10 March 2007 (CST)

Briefly, in the UK there are four accredited Colleges, two University based and two asociated with Universities. Accreditation by the GCC requires a 4-year approved degree programme leading to a BSc in Chiropractic. I've looked at the University of Glamorgan site, and the academic side is much stronger than I'd expected it to be (just showing my ignorance and prejudice here). About its training, it states "The profession enjoys independent practising status and emphasises that it is not an alternative to conventional medicine. This course is designed to train chiropractors with an advanced knowledge of human structure and its relationship to general health, plus the ability to diagnose and treat those conditions considered likely to respond to chiropractic management." Students for this degree are taught spinal mechanics by a PhD physiologist actively researching spinal mechanics (in animal experiments, trained in Calgary) whose modules are available to students from several other degree programmes; i.e. the underlying science in the initial years at least seems to be taught from a conventional basic science perspective, and is integrated with the education of other health professionals (not medics, their education here is not integrated with anything else generally). See [3]Gareth Leng 06:02, 10 March 2007 (CST)

Well, I think that we have to reflect the seperation of chiropractic and the health sciences in the USA here, and include a couple of lines in that in "critical views". I'd like to talk this out here on the talk page, because I want Matt's view and very much want him onboard. Let me back up for a minute and suggest, barring the better solution of having chiropracters from other countries collaborate, that we should investigate with due diligence and find out if chiropracters not only share their education with other health professionals in the UK (and we need to look at other countries one by one) but also share practice facilities- do they roiutinely go to hospitals and government financed clinics, for example? In the USA-and this goes also to te discussion we are having Gareth in the History of Medicine (United States), underegraduates that are "pre-med" take the same courses in college as sceince majors who will go on to get Ph Ds in research science. That is also true of the undergarduates who will go on to Dental School. Most colleges have less research oriented courses for Nurses and physical therapists, although the title of the course may be the same- the difficulty and hours in the lab are not. Here comes the critical part-in the USA, to the very best of my knowledge, DCs are educated entirely separately and have their own schools-not the common universities attended by the others, and are, perhaps with rare exception, never integrated into the common health system of Dentists, Doctors (MD), nurses, (RN) etc. This may be an unfair artifact of past exclusion- but there is another side that is important. It is an entirely different system of care. There are chiropracters, like Matt, who refer to hospitals and health science physicians and programs, but that is an individual choice on his part that does not reflect any integration of care for the typical patient of a chiropracter into the health system. In fact, some chiropracters offer full primary care to patients, men, women, and children, (I guess these are "the straights") and there is no general formal or informal system in place to see that such patients also received attention by the Health Sciences. Like with extreme Christian Scientists, patients who under the care of these heaqlers, unless they themselves independantly seek out health care from the generally recognized central health care system, will not receive it. So, for example-there are articles in the US medical literature that analyze why it is that the death rate of breast cancer is higher among black women than white women-even though the rate of the disease is much higher in whites. I'll get that reference when I finish this post. There are many reasons given in this article, basically having to do with late presentation, but one of the reasons for late presentation to MDs that treat cancer is because, in the area of the US where this study was done- black women were disproportionately undereducated, less affluent, and underinsured, as compared to white women, and, like others of that demographic, more likely to seek chiropractic care when they finally did seek attention, and then less likely to get attention from the health system, because it is separate. Now, some of the concern that exits about chiropractic in the US is that those who seek chiropractic care are not getting attention within the broader health system, but outside of it. That was my point about the straights and vaccination, though I didn't make it very well, you see if a parent brings their infant and young child to one of the straights that do noty believe in vaccination (and my understanding from their own lieterature is that none, or almost none, do) that child may well be entirely outside of the health system- never being examined by a nurse or doctor. In other countries, this may not be the case- but it is not reasonable to present Chiropractic as incorporated into the health system in the USA just because it may be elsewhere. I strongly believe that the efficacy of chiropractic care be properly supported, but I also strongly believe that these risks of lack of standard medical care by explicitly addressed. Nancy Sculerati MD 09:27, 10 March 2007 (CST)

late diagnosis reference

Lannin DR. Mathews HF. Mitchell J. Swanson MS. Swanson FH. Edwards MS. Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. [Journal Article. Research Support, Non-U.S. Gov't. Research Support, U.S. Gov't, Non-P.H.S.] JAMA. 279(22):1801-7, 1998 Jun 10. UI: 9628711

OK to summarise in the UK, medical student training is not generally integrated with that of science students. It is skill based not theory based. Training of chiropractors is well integrated with that of science students and other health professionals (ie they taught a high proportion of modules) in 2 of the 4 accrediting institutions. In the UK chiropractic seems to be moving towards fll integration. However, chiropractic is tiny in the UK; theres no doubt in my mindthat this article should reflect the US reality whatever that is.Gareth Leng 12:32, 10 March 2007 (CST)

I think you have to investigate that on your own Gareth, because you are acting as an editor here and I think Matt's view is extremely sympathetic towards Chiropractic and not a neutral mainstream US view. My view is sceptic but not condemning-but there are no chiropracters in any academic or major medical center that I know of, and certainly not that I have ever had contact with, and so I only know what I read and what Matt says. There have been times that you have intervened as editor here when I assumed that your perspective came from knowledge of the field. Some of the nutty comments we have had about quacks and such are nutty, but may have been provoked by the unusually sympathetic view of chiropractic presented here. Again, although there may be some regional variations, in the US chiropractic is alternative medicine in the sense that it lies entirely outside the established network of dental, medical, nursing and physical therapy health network, is not included in hospitals and is not integrated into the health sciences. Whereas a nurse or physician's assistant or physical therapist is required by law to refer to a Physician if certain health conditions occur- and is also required to do that by professional ethics, a chiropracter is not- in the US. If I am wrong, it is from ignorance-but that is what I think and I can find nothing in writing to refute it. Nancy Sculerati MD 13:06, 10 March 2007 (CST)

None of us knows it all which is why we need to work together. In the UK it's clear thatwhat you suggest is not true, in that the chiropractic is regulated very tightly by the GCC, which is a government established body with very similar role and ower as the General Medical Council. In the USA, I see that most medical schools in 1988 offered electives in CAMs and that chiropractic was one of the most common of these (JAMA 1998 280:784-778 [PMID 9729989]); there have been surveys of referrals and willingness to refer to chiropractors in the US, I recall finding one of these if that's relevant. I think there is the expectation here that all subjects be treated sympathetically. To my honest best knowledge the article as it stands is accurate and makes no major negative omissions of verifiable fact which I'm aware, except those covered in the Criticism article. The Wilk case report is verifiably accurate from the published judgement. I'll keep lookingGareth Leng 16:51, 10 March 2007 (CST)

I think the Wilk case is accurate, and the elecetives now offered in medical schools exist, but rarely if ever as the kind of apprenticeships that medical subspecialty electives exist as- instead as "informational electives". Aromatherapy and prayer healing are also covered, that is not to say that these are incorporated into the curriculum as standard therapies. I'm not saying that chiropractic should be presented without sympathy, I am saying that in the US it is misleading to present the chiropracter as just one more kind of doctor or health professional that is in the system, because chiropractic is not within the system and some chiropracters actively encourage their patients to avoid the system because they believe that drugs, vaccinations and standard medical care is a poor choice. That side of it has to be made clear- as well as the fact that chiropractic care for back pain is at least as good as non-surgical medical care and physical therapy. But I would like to see what Matt has to say, and how this can be worded in an agreeable manner.Nancy Sculerati MD 17:35, 10 March 2007 (CST)

in the US it is misleading to present the chiropracter as just one more kind of doctor or health professional that is in the system, because chiropractic is not within the system and some chiropracters actively encourage their patients to avoid the system because they believe that drugs, vaccinations and standard medical care is a poor choice.

I think this is the only sentence that I can respond to, as I don't have access to the breast cancer source. The clarifying issue is the word "system". Chiropractic is within the "healthcare system". I agree that it is not within the "medicol system". Though Wilk broke down some barriers that allow doctors to develop personal and individual relationships, there is still a wall of distrust. I have my doctors that I refer to as well as those that I wouldn't. I think politically, the government would like to see it better integrated, but professionally the two fields are still separated by animosities (real or imagined) as witnessed by the Florida debacle a couple of years back where Jeb Bush (Governor of Florida) requested that chiropractic be integrated into the university of Florida, but was refused because professors threatened to resign because they thought it was a pseudoscience (real or imagined). The second part of the sentence (real or imagined) is probably the reason they are not allowed into the "medical system". I did find some examples of the type of thing that chiropractors read [4],[5](notice who wrote this one-we already cite Lon Morgan once - again this is the internal dialogue within the profession read the last paragraph - makes Nancy's argument). Maybe we can integrate it somehow. Though this is probably more appropriate for the antibiotic and vaccination articles. That is a whole new bag of worms and obviously this is not what defines chiropractic because I think all the schools take a neutral stance on vaccination (I'll check though). I think our section on Chiropractic approaches does as good a job illustrating the different outlooks on these, but maybe we can clarify them more. We should be able to find some sources on this.

While we are on the subject, I don't think starting the introduction with a "slap on the back" is appropriate without a reference. I have never seen it, but I left it in from the WP article. If it is going up front, let's see it. --Matt Innis (Talk) 20:01, 10 March 2007 (CST)

Matt. what I was thinking in the "couple of lines" in the Critical view section was something like this (this is unpolished-just writing it as I think it:): 'One result of the long history of distrust between the system of hospitals and health science professionals on the one side and chiropractic on the other has been the exclusion, until recent years, of chiropractic from the general health care institutions of the United States. When patients are cared for by those chiropracters who do not accept health science, then these patients may, sometimes without realizing it, enter a truly alternative system of care, where the standard diagnostic and therapeutic methods for disease are not used. In some cases, this has been cited as a reason for the late diagnosis of serious diseases.' Whether or not most Schools for DCs try to take a neutral view, there are more than a tiny number of practicing DCs (I guess straights?) who do not. Just as, I'd say, most schools of medicine take an officially neutral view towards alternative medicine and chiropractic, might even offer courses on the topic (though-as you point out about Florida- it is not as though Chiropractors are on the faculty)-again, I am sure that you have a network of physicians that you refer to, and that there are those that refer to you, but that is an individual private practice arrangement. There are chiropractors who never refer to physicians and physicians who never refer to chiropractors. There are chiropractors who never refer to physicians even if a patient is ill. I don't say they do this without good intentions, but breast cancer diagnosis and heart disease diagnosis as performed by health science is not chiropractic. Nancy Sculerati MD 05:38, 11 March 2007 (CDT) Also Matt, when you say "health care system", yes- the Government and private health insurers will pay chiropractic fees, and so in that sense Chiropractic is part of the health care system as recognized by insurers and the Government, but I am talking about a patient's access to standard medical care, a patient being "in" the standard health care system. When a patient ivisits a Chiroptactor, in general, it is not in a medical center or hospital but a private office or a strictly chiropractic group that is OUTSIDE the heath sciences. There is more to vaccination, for example, than just the vaccination- apparently well children are seen by doctors, nurses, and physician's asistants when they get vaccinated and conditions unsuspected by parents are sometimes picked up. The fact that children get a series of vaccination early on is a kind of a fail-safe in having medical attention. If children get their primary care from chiropractors- as offered by some chiropractors who advertise that the offer full care including primary care for children and prenatal care for women-and are not vaccinated they also are not seen by the standard medical people, I don't want to get lost in semantics here, and in that sense they are outsde the health care system. I feel obligated to make this clear because in other countries it sounds like this is not the case. Here, chiropractors- even those who do refer to MDs and DOs (both of whom are within the greater health care system with admitting privileges to hospitals etc), are not themselves able to admit patients to hospitals. There may be some hospitals where chiropractors can consult on patients, but I do not know of any. In the US, chiropractic is not integrated into the standard hospital/health care system. They are separate, and there can be consequences for patients if the patients don't know enough to seek help at the hospital and the chiropractor is distrustful of the medical system. My concern is that this article makes it sound as if it is not that way-like this is Scotland, say, where that does not appear to be true. Matt- you phrase it so that it is not offensive to you, but please-tell it like it is. NancyNancy Sculerati MD 05:50, 11 March 2007 (CDT)

Good to talk

I think we are covering some very important issues relating to neutrality here, and it's good to talk over them professionally. I see Nancy's concern, I just am not sure how to accommodate it properly. A man may swear to tell the truth, but it is not in his power to tell the whole truth and nothing but. “Truth is so subtle a point that our instruments are too blunt to touch it exactly. When they do reach it, they crush the point and bear down around it, more on the false than on the true” (Pascal) The important issue is that we must trust each other's integrity, we are all trying to tell it like it is; we need each other because we have to tell it like it is in a way that we all understand to be true

If we take statements from the AMA, NIH, NHS etc at face value, then I think the article has a tone that is less “sympathetic” to chiropractic than these. So the issue is this: Regardless of what the AMA says officially, and regardless of what is in the peer reviewed literature, many hospital-based physicians in the US are disdainful of chiropractic, and at present this is not adequately reported in the article. As I understand, these physicians work in an environment from which chiropractors are excluded, so the basis for that disdain isn't an obvious matter of direct experience or of verifiable record. My inclination has been that we do not report them, any more than we would report what we think our colleagues really think for example about the standards of medical education in other countries, such as the Indian subcontinent from where many of our health professionals come. Yet as Nancy says, not to report them invites the appearance of bias, ....and yet to report them and not counter them would involve the reality of bias.

Perhaps we might acknowledge the concerns by saying that.

“At present, although many family physicians are willing to refer their patients to chiropractors, chiropractic is not integrated into hospital-based medicine. Many hospital based physicians and academic scientists remain skeptical about the scientific foundations of chiropractic as well as its efficacy for conditions other than some directly associated with the spine, and so remain concerned that some patients who choose to be treated by chiropractors may in some cases be denying themselves the benefits of more efficacious treatment by conventional medicine. They are also concerned at occasional examples of abuses by individual chiropractors. Chiropractors on the other hand believe that these attitudes reflect a lack of understanding of the true nature of chiropractic today, that reflects in part the very separation of chiropractic from hospital based medicine.”

I wrote the above before reading Nancy,s message above so please dont see this as an alternative suggestion; just as a suggestion.Gareth Leng 15:39, 11 March 2007 (CDT)

Thanks, Gareth, for your elegance. Certainly truth is not within my grasp. I'm still waiting to find out if Jesus was real:) Seriously though, all I can do is try to enunciate the truth according to myself, as I assume we all are doing here. I don't have too much trouble with what either you or Nancy are saying here. Certainly both statements are true for somebody. I would really like to see references to support the statement that chiropractic patients are at a higher risk of mortality or morbidity before I would give credence to the assumption. If this were the American Opticians Society making this statement, that would carry a certain amount of weight, but when you place the weight of the AMA behind a statement like that, you expect some scientific analysis and give it more weight. So even if you call it a "maybe" or "possible", when it is attributed to the AMA, it means something more, so lets get this right. We talk about Evidence Based Medicine as a means to determine efficacy regardless of theoretical mechanisms of effect, certainly science can give some idea of whether the assertion is accurate that an alternative education results in a higher risk. Otherwise, this is just someones nightmare that has been marketed well. So, before we make this statement, lets at least verify it or attribute it to the correct group of people so that the proper weight can be applied. I see no problem with highlighting that the two are separate, but to make value judgements based on that separation is a different discussion altogether. Thoughts? -Matt Innis (Talk) 07:44, 12 March 2007 (CDT)

OK maybe my head is hurting here Matt. Did I assign any statement to the AMA? I haven't seen any statement from anywhere attributing higher mortality or morbidity to chiropractic and didn't think I'd said that anyway. What I have been doing is trying to hunt down documentation of the kinds of reservations that Nancy is describing. The best I have found is here [6] where the AMA do say a number of interesting and relevant things about chiropractic. I'll pick out highlights.

1)Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints, and some chiropractors limit their practices to these conditions. While precise statistics are not available, a majority of chiropractors adhere to the method’s original theories, and continue to claim that chiropractic manipulation cures disease rather than simply relieving symptoms. (Personal communication, Denny Futch DC, Vice President, National Association of Chiropractic Medicine). They promote manipulation as useful in a host of conditions, ranging from infectious diseases to immune therapy, even claiming to prevent future conditions from occurring (even if years away) including menstrual irregularity, difficulty giving birth, and cancer. Chiropractors commonly provide advice in nutrition and other preventive practices, and maintain that a regular series of "adjustments" is needed by most persons to maintain optimal health. 2.In a national survey of referral patterns by board-certified family physicians and internists, ... 47% said they would refer for chiropractic 3.AMA Policy 1997 "Patients who choose alternative therapies should be educated as to the hazards that might result from postponing or stopping conventional medical treatment." (not specifically chiro) 4. Of 125 US medical schools, just over 50 schools offer elective, for-credit courses on alternative therapy, and 18 others offer lecture series or seminars on the subject. Most are being given by "supporters or proponents of alternative methods," and that the "scientific view" is offered in only 7 courses.(not specifically chiro) 5. In their advice to members the AMA says "Avoid hubristic and arrogant attitudes toward alternative medical practices because one might be embarrassed by the subsequent demonstrations of their clinical efficacy." (not specifically chiro)

Suggest that these be the basis of any inserts about attitudes of the medical profession in the US? Its nearly 10 years old but....Gareth Leng 10:28, 12 March 2007 (CDT)

We are dancing around terms here. First, when NIH or other authorities make statements about the "dangers of chiropractic", it is the specific risks of chiropractic therapies that are being discussed- stroke with cervical manipulation, etc. Not the risks of regarding a chiropracter as a comprehensive primary care physician, when, in America, chiropractors are not legally allowed to practice Medicine. In the United States (we don't say "of America here unless we are forced to by Brits :-) (and others)) the term physician means a person who has an unlimited license to practice medicine, and although osteopaths are eligble for that, as well as MD, chiropracters are not, and that is simply true. A hundred years ago, especially in the frontier west and in rural areas, that was not true, and chiropracters were one 'sect' (to use Abraham Flexner's term in the Flexner Report) of physicians. Presently, chiropracters are licensed health care professionals, but not to practice medicine- to practice chiropractic. For whatever reason, and the Wilks case makes a strong argument these reasons were unfair, not only have chiropracters not been physicians for a century, but for a good part of that time physicians in good standing had nothing to do with them. I'm trying to figure out how oseteopathy came to have such a different outcome, and so far it seems to be that their organization insisted on meeting Flexner's standards for education, where as Chiropractic has never been organized in the same sense as the AMA or the Council on Osteopathy. It seems that in the interval, school of chiropractic have raised their standrads, but these schools have remained separate from the Medical (including Osteopathic) Dental and Nursing Schools, which-despite being separate, have frequently been on joint campuses, and shared laboratory and clinical facilities. But I digress- all this time there has remained a 'sect' of Chiropractors, mixers? straights? maybe some of both, who still see themselves as practicing medicine-what Matt calls chiropractic as an 'unlimited profession'. Matt, with al due respect- I do not base my understanding of medicine strictly on my own experience and it is unreasonable for us to produce a document with (hopefully) global impact that is based on one chiropractor's experience, especially one who is not involved nationally in Chiropractic, even if that person is as nice and smart as you. A purusal of the very external references that you have given us back in the section on different types of Chiropractic shows ads-not even by individual chiropractors but by organizations, that present the chiropracter as able to offer a full comprehensive primary health care.Since drugs and surgery are not involved, I guess technically it's not "Medicine", but since drugs and surgery are seen as harmful to patients, the effect is a true alternative medicine where patients who follow these teachings are treated in a comprehensive fashion away from the larger health science system. I can e-mail you the text oof the reference on late diagnosis on breast cancer, which is nothing more than a compilation of what held up diagnosis in a series of patients, and one reason was that these mostly poor and rural woen sought health care from their local chiropracter rather than physician. It's not that anyone is accusing the chiropractors of knowing the women had tumors, the point is that they had their backs adjusted and not their breast cancer diagnosed. In rural areas of tour country even now, and in poor areas, there is still a tradition of DCs acting as physicians and -since they are not "plugged in" to the larger health service network as a group, in fact the very chiropractors who see chiropractic as being unlimited, who teach that vaccinations weaken the immune system, and that medications given by MDs and DOs cause at least as much harm as good, are the very chiropracters who are, logically, least likely to interact with physicians. It is possible to read the article we have written and not realize that chiropractors are not physicians or that the "unlimited" care some offer is -in the Unites States of America not a recognized form of Medicine, and not necesarily a portal to standard medical care, either.m It doesn't matter that that may not be true of "most" chirpractors-it is true of certain sects. Nancy Sculerati MD 10:54, 12 March 2007 (CDT)

??

OK. think I'm starting to see things more clearly from both perspectives, sorry if I've been slow. First, we have to report significant opinions, and I accept Nancy's case that a significant opinion was not adequately reflected, specifically the opinion that chiropractic deflects some patients from effective medical care. This is expressed in the AMA report so I am certain that we should report it. I don't think we should state it as fact but as notable opinion, and I think we should just report it straight. (chiropractors might argue the converse, that if only 47% of family practitioners are willing to chiropractors then they might equally be denying some patients more effective care :) let's not go there.)

However in all honesty Nancy, as I read and re-read the article I don't know how anyone could have been misled into thinking that chiropractors were anything other than clearly distinct from physicians and separate from organised medicine. From the very outset, what chiropractors do and think is constantly contrasted with views of conventional medicine. However, does the revised Criticism section meet your concerns? I've also trimmed the Wilk section down according to my suggestion above. I am not trying here to make a unilateral decision, just inviting you both to look at the overall balance now, afresh.

I seem to be in the middle; actually I feel myself to be off on some third dimension, two thousand miles away. I have to admit I see several sides here. I do find it uncomfortable that the AMA attacks chiropractic for not having an integrated training yet seems to actively prevent such integretaion (in Florida etc.), and can certainly see, in the wake of Wilk, how this might be seen as active suppression of a competitor. I'm glad I'm a long way away sometimes....Gareth Leng 12:21, 12 March 2007 (CDT)

Gareth! You are in the middle! You didn't realize that:) And you are doing a wonderful job of it, too. I'm sure I speak for Nancy when I say we both apprecite your helping us through all this. I haven't had a chance to read through all the changes, yet, but will later this evening.

Nancy, thanks for the breast cancer research. It was indeed enlightening and illustrates your point well. This strikes close to home for me here in North Carolina and I will certainly look into this to see what kind of follow up has occurred.

By the way, while I agree that I am a nice and smart chiropractor:), hopefully I am also a good resource for this article. In the last year I have spent literally thousands of hours researching. Please feel free to look through my notes. [7],[8],[9]. I would also suggest the Lerner report that was used in the state of New York. There is so much more that I haven't even touched on. If you find something like this that contradicts what I have been trying to convey, please feel free to bring to my attention and I will integrate it into the rest of my knowledgebase. Thanks! --Matt Innis (Talk) 16:25, 12 March 2007 (CDT)

Well, that breast cancer article really just emphasizes beliefs, but it's worth including,I think. I just read through a good deal of the Flexner report and am fairly stunned by the racist and sexist assumptions, not to mention the overwhelming arrogance that permeates the thing. It's shocking to me because I approached it with a feeling that Flexner was a hero, not only beccause of medicine but also because of the Institute for Advanced Study. His idealism was not quite the brand that I imagined. Of course, I must remember the times. I put a link to it at the Flexner Report and I swear, if you read it you'll find yourself looking to call the constables every other sentence -for inflammatory language and needless insult. After reading what he said about the schools of osteopathy, I am even more intruiged that they survived. I suspect that they were well financed after the report - they were certainly doing well on a business basis. Thanks, Matt for your Still autobiography link! And Gareth you are nort in some 3rd dimension, we are all in that one-I'd say 5th or 6th! I think that both Matt and I see things from a patient point of view, and in that way we understand each other, and I'm happy with the changes made. Nancy Sculerati MD 17:42, 12 March 2007 (CDT)

No problem with the Still link, Nancy. If you want to get a really thorough understanding from a unique point of view about chiropractic, read the Lerner Report above. It will change you whole outlook. This guys did his own research, going and talking to key people and digging up all kinds of stuff and put it together. It is so thorough but it reads like a mystery novel. He talks about many people addicted to the common treatments laced with alcohol, heroin, and mercury, all killing more than they were saving. If we were living back then, we would have been glad to see Still and Palmer come along. It is guilded with intrigue and cloaked with deceit and mysticism that boggles the mind. He links Rockefeller (horizontal economics buying up all his competition), Carnegie (vertical economics buying into the raw products and sending them through his production line to marketing until he had the consumers dollar), presidents in the pocktets of big money and the pinnacle of social and scientific revolution. It notes that Germany was the center of modern chemistry and patent medicines. Britain was the center of homeopathy and natural remedies. The Americas were young and immigrants were unloading in New York by the thousands. It was exciting and new markets for British and German products were opening everywhere. Competition was tight. Flexner worked for Rockefeller who was German with financing from the Carnegie foundation? Guess what schools they closed, uh huh, homeopathic. Don't forget, we're talking about 1910! Britain was the most powerful nation in the world depending on its trade with other nations, but Germany was becoming the industrialized power of the world, ... guess who have the two biggest navies... yep, Germany and Britain... and the rest is history... 1917 WWI. It's the stuff novels are written about. We were nothing but pawns being played by a giant European chess game. Fun, but nothing that we can use here (maybe on the workgroup page), but it sure is a mind opener. I better see what changes were on this article before I ramble too much. -Matt Innis (Talk) 22:05, 12 March 2007 (CDT)

Well, there are always conspiracy theories. I see it differently so far- Halsted and Osler were at Johns Hopkins, not to mention Cushing and they were putting things together- histology and chemistry and surgery and going lightening fast. The cocaine and morphine helped things along, but nobody was better at adjusting doses than them, I'm sure. They had their own labs, their own operating rooms, their own wards and their own pathology labs. They examined patients, biopsied tumors, looked at them under the microscope, operated on the living flesh and autopsied the dead. They described whole fields of medicine and were able to do things nobody had ever done before. They were brilliant intellectuals and wealthy and cultured men, and Flexner, snob that he was, LOVED them. He -Flexner-saw patients as "clinical material", strictly the raw material for a type of education. He saw the future of scientific medicine as rapidly unlimited and despised the unlettered non-intellectual booster businessman of the midwest and south. He founded the Institute for Advanced Study, and I grew up in that culture- by accident- where I lived, the families of my friends when I was a kid. Like I say- I see it differently. Nancy Sculerati MD 22:29, 12 March 2007 (CDT)

Wow, you did have a unique perspective! No wonder you feel so strongly about it. Don't get me wrong, scientific medicine was the way to go and Flexnor did what had to be done, but to deny that there was a financial incentive would be naive, especially in America, land of capitalism. I'm not saying it is a bad thing, but we can't assume that all of healthcare is about the altruistic endeavor to help patients. If that were the case, we would still be collecting chickens for our pay. You have to ask yourself why countries that have social systems don't seem to have the same problems with chiropractic that the US has. --Matt Innis (Talk) 22:59, 12 March 2007 (CDT)

They don't have thousands and thousands of chiropractors "in business". Nancy Sculerati MD 23:37, 12 March 2007 (CDT)

still needs work

Made a quick read through and saw several edit problems, but didn't change anything as it is getting late here. I still am not satisfied that the introduction fairly portrays Palmers discovery, but will work on it later as well. I miss the prose from the old article that seems to have been lost in our newer version. Maybe if we take a little break and come back, we will see it in a whole new light and we can make it flow better. I'll take another look tomorrow. Overall I don't see any problems with the AMA and critique sections. -Matt Innis (Talk) 22:23, 12 March 2007 (CDT)

Did a quick clean up, just smoothing some of the prose. I've adjusted the account of the hearty slap; both versions are given later, so up front I left it open "(by accident or design)". All the references are now linked for online verification.Gareth Leng 04:45, 13 March 2007 (CDT)

Gave my once or twice over, added some wikilinks (more red links to click on!), and made some minor changes to the intro that I think I can live with. Otherwise a good nights sleep seems to have made everything look better:) -Matt Innis (Talk) 08:52, 13 March 2007 (CDT)

Matt - can you archive most of this? I know I'm an incompetent. I think the article is missing an illustration, I know it will take the limit over but I think it would be in a good cause. I suggest this [10]

Regardless of this, looking to the launch are we ready to reapprove? I am. I'd also like to approve Critical views of chiropractic before the launch to show balance. Gareth Leng 08:58, 14 March 2007 (CDT)

Safety

Mackay B. April the cruellest month for Canada's chiropractors. [News] CMAJ Canadian Medical Association Journal. 166(12):1576, 2002 Jun 11. UI: 12074130 discusses some law suits, and the fact that the Canadian Nation Health service stopped paying for pediatric chiropractic care.

Jones J. Neurologists warn about link between chiropractic, stroke. [News] CMAJ Canadian Medical Association Journal. 166(6):794, 2002 Mar 19. UI: 11944773"More than 60 Canadian neurologists have issued a statement warning that chiropractic neck manipulation can cause stroke and death. The neurologists and the Canadian Stroke Consortium caution that chiropractic manipulation involving the neck can cause arterial dissection. They make 6 recommendations and call for a ban on manipulations involving infants and children. “If there are no clear benefits, any risk is unacceptable,” says Calgary neurologist Brad Stewart."

Meeker WC. Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine.[see comment]. [Review] [164 refs] [Historical Article. Journal Article. Research Support, Non-U.S. Gov't. Research Support, U.S. Gov't, P.H.S.. Review] Annals of Internal Medicine. 136(3):216-27, 2002 Feb 5. UI: 11827498

"The evidence to date indicates that the risk associated with chiropractic manipulation of the neck is both small and inaccurately estimated. The estimated level of risk is smaller than that associated with many commonly used diagnostic tests or prescription drugs. On the other hand, the expected benefit from the manoeuvre is also difficult to quantify. Systematic reviews of the literature and ratings of appropriateness by an expert panel 5,6 suggest that cervical manipulation or mobilization, or both, provide short-term pain relief and range-of-motion enhancement for the subgroup of individuals with subacute or chronic neck pain. The evidence to support the benefit of cervical manipulation for other indications, including acute neck pain, migraine and other miscellaneous conditions, is far less compelling."..."What are the practical implications for patient care? Chiropractic care is common, and the vast majority of patients experience no adverse effects; however, the potential risk of stroke is not zero. Given the potentially devastating consequences of arterial dissection, physicians and chiropractors should discuss this risk, however small it may be, with patients contemplating neck manipulation. As with all clinical interventions, the expected benefits of cervical manipulation should not be overstated. Whether the potential risk of stroke is acceptable is a matter for the patient to decide, and the decision will probably, and legitimately, be informed by the patient's subjective assessment of the severity of his or her symptoms and the desirability of this form of intervention."

several case reports [11]

Rubinstein SM. Peerdeman SM. van Tulder MW. Riphagen I. Haldeman S. A systematic review of the risk factors for cervical artery dissection.[see comment]. [Review] [66 refs] [Journal Article. Review] Stroke. 36(7):1575-80, 2005 Jul. UI: 15933263 note:Haldeman is a DC and an MD and has written pretty extensively on the subject.

Thanks Nancy. Does this mean that you think the safety section needs expanding?

My view here is that we should not go much beyond reporting official advice to patients from e.g. NHS, AMA, NIH. The Canadian neurologists "warning" was given at a press conference announcing the ourset of a study to investigate these very risks, and on the basis of preliminary data. As I understand it, the full study did not support these risks, and the early warning was based on data affected by reporting bias. Ay least that's my memory, which may be unreliable, but I think that's how it appeared when I tried to chase up the outcome of the full study.

I think we need some policy guidelines on such issues in all medicine and health sciences. In my view in general and not just here, articles on Citizendium should avoid appearing to draw its own overall conclusions about either risks or benefits, but may report conclusions drawn by others (attributed, notable sources, major publications), and should report advice to patients as given (for instance) by the AMA or NHS. Articles should not cite case reports (anecdotal evidence, selection bias), but may cite large studies published in major journals, and should give links to evidence-based medicine resources, (systematic reviews, Cochrane etc.).

As always, the issue is how to discuss risks neutrally. It seems to me that reporting official advice and information is straightforward, as this is us reporting advice not giving advice. Where there is dispute about possible risk then both sides must be presented in a balanced way, and I’m not sure that this will lead to clarity. This is why my preference is simply to allude in an uncontroversial way to the possibility that there may be such risks, and refer the reader to reviews and major studies.Gareth Leng 06:20, 15 March 2007 (CDT)

I don't thibk that the evidence argues that spinal adjustments are unsafe, but, at the moment-the entire safety section says :As with all interventions, there are risks. In spinal manipulation risks include: vertebrobasilar accidents, strokes, spinal disc herniation, vertebral fracture, and cauda equina syndrome. A 1996 study showed that the greatest risk is from manipulation of the first two vertebra of the spine, particularly passive rotation of the neck. Serious complications have been reported to be 1 in a million manipulations or fewer, but there is uncertainty about how these are recorded; a survey in 2002 of neurologists in the UK concluded that underreporting rendered estimates 'nonsensical'.[18] Few studies of stroke and cervical manipulation take account of the differences between 'manipulation' and the 'chiropractic adjustment'. According to a report in the JMPT, manipulations administered by a Kung Fu practitioner, general practitioners, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber had all been incorrectly attributed to chiropractors.[19] I had thought that this article was going to be very sympathetic to Chiropractic and that Critical Views of Chiropractic would balance that. I now have a different understanding. I think the safety section here should actually be scholarly and include everything, as it is, it 's written to be reassuring and includes no review of the actual literature. I also -now that I have been reading, have a problem with the section on "The 3 rivals of the 19th Century". Chiropractic was not one of 3 rivals in the USA- there was modern medicine, based on science whose practitioers scorned the term allopathy as they consider that a medical "sect" not based on rational understanding, allopathy, homeopathy, eclectic medicine, osteopathy and chiropractic was not even in most of the USA, except for the rural areas and the midwest. in the 1910 Flexner report, chiropractic wasn't even included. Nancy Sculerati MD 07:18, 15 March 2007 (CDT)

Exactly, Nancy, that was my earlier point that we were putting in to much about the Flexnor report. At that point in history chiropractic was a spec in the dust compared to homeopathy that was bigger than scientific medicine. The real battle for Flexnor was homeopathy - these schools did not even have labs to evaluate their own products. Anyway, Andrew Still's osteopathy was taking off as it was 10 years older than chiropractic and had been developing a large following, Palmer just started his clinic and only had 7 graduates by the end of the 19th century (and yes, several were MDs), but he was very vocal with his advertising cures. But Flexnor was after homeopathy initially. Still, being an MD, understood the implications and immediately began to upgrade his quality - including developing accreditation standards and laws to protect his schools. Both Osteo and chiro did not go east - they went to california. Flexnor didn't care about them and by the time he did osteopathy had already developed their program and political base. Initially, it was osteopathy that went after chiropractic, not medicine. I tried to keep it as succinct as possible using the information at our disposal. Let me know if you think something is not correct. I agree the title change to "of the 19th century" is misleading. --Matt Innis (Talk) 08:47, 15 March 2007 (CDT)

Matt, I am getting frustrated altogeher with Chiropractic. I regret giving my approval to the first article. I assumed that both you and Gareth had extensive knowledge, and I added my part. Now I see that I myself have written things here that are just plain wrong, and that they were not removed or corrected. I suggest that we remove the approval template from Chiropractic and work on the draft to make it accurate. And you are wrong about Flexner-he went to California, he reviewed every school considered a "Medical School". It's a long report-but I put the link to it at the bottom of Flexner Report and it's all there. It's hard to do real scholarship, but that's what this article needs. Unless we can recruit individuals who are experts on the subject, the history and practice of Chiropractic as a global profession, I think we have to accept that it will take us a matter of at least weeks to come up with an article that is accurate. Nancy Sculerati MD 09:31, 15 March 2007 (CDT) Well, I've settled down. I may be wrong, you may be wrong, but we are only human and we are trying very hard to get it right. I have reflected that, of all I've read, this has got to be the best single article on Chiropractic I've come across yet and so forget about redacting approval. Please take a look at what I wrote about an integrative view in the talk page for Critical views of chiropractic, and I think we can re-approve this very shortly. Yeah, it would be great to have the World Expert on board, but I'm not so sure there even is a world expert that's also in tune with mainstream medicine and science, and that's, of course, who we actually need. Nancy Sculerati MD 15:56, 15 March 2007 (CDT)

Polio

I've expanded a bit on the polio vaccine just to try to illustrate a bit better why the AMA embraced science and where the division with chiropractic lay. Please checkGareth Leng 05:51, 16 March 2007 (CDT)

revised 19th century section

I am working on a word document to try to get narrative down that explains the background of Medicine and Chiropractic began the AMA suit that I think is important. It's not, I see, that the Chiropractors were so influenced by Flexner and his ilk- it's that the American Medical Profession was. Osler, Cushing and that whole movement of like minded physicians that revolutionized modern medicine in the USA despised allopaths and MDs who adhered to folk remedies and who were not learned or expert in science. By changing the requirements for medical schools that could give the MD and OD- I include both because over the 20th century the actual practice of the OD became pretty indistinguishable from the MD, the nature of American medicine was changed, in its ideal. Even now there are plenty of physicians who scoff as science, see themselves as bussiness men etc- but the Osler/Flexner Contigent (my name for a school of thought) put a stamp on American Medicine as a profession that drove out the heroic healers and sects in Medicine from the 19th Century. I think that an article on Medicine has to show how this movement ended up having a down side with depersonalization of patients, reliance on the trappings of science without demanding true scientific thinking, and other things- including over-prescription (BTW Gareth :-) ) but if I can paint tis picture correctly, it will increase an understanding of why idealistic people in the AMA may have pursued chiropractic. I have no doubt that the Judge was correct, and that there was a business issue here. My point is that I want to show how the idealistic paradigm of modern scientific medicine had reason to abhor the culture of chiropractic. I other words, the kind of ancedotal evidence and willingness to accept temporal association as causality that are still evidenced by the Chiropractic journals are found in Medical Journals of an earlier era - and it was that idealistic scientific academic leadership in medicine that crushed it, at least confined it to private converstaions among physicians and drove it out of being acceptable in journals. So, I'm trying to rewrite this to include that view. Nancy Sculerati MD 09:00, 16 March 2007 (CDT)

I think you are talking about some interseting stuff that needs to be written. It sounds like it needs to have an article all to itself. Keep in mind that MDs and DOs education is very similar now, but that is only since the mid 20th century. Still was anti drug all along until he died. Some of the best research on spinal manipulation came out during this time and was performed at DO schools. One of the reasons that chirorpactic cites as not to join medicine is how DOs lost the art of manipulation when they began to use medications. This is why all but a small reform group (NACM) do not want to see chiropractic prescribe. It would be too easy. Chiropractors identify themselves as manipulation using in an effort to avoid surgery. --Matt Innis (Talk) 09:44, 16 March 2007 (CDT)

Matt, when you say surgery-you mean back surgery? Nancy Sculerati MD 12:27, 16 March 2007 (CDT)

That is a good question. Yes, certainly back surgery, but a subluxation based chiropractor would look at it as if he/she prevented a health problem, he/she may have prevented a "future" surgery.

disambiguation fine print

I added that top line because it struck me, that Veterinary is a whole different deal that we do not have room for here. I'll make a stub for it. It is very big among the sport horse people- around here, anyway. Nancy Sculerati MD 19:50, 16 March 2007 (CDT)

This is my wording I think "One day, by accident or design, he gave a deaf friend a slap on the back that caused a "pop" in his spine, and both noted that the man's hearing subsequently improved."

This gives only one side of the story, Palmer's version was that this was a deliberate and precise adjustment. Both versions are given later, but how should we rephrase this when it first occurs?Gareth Leng 13:08, 21 March 2007 (CDT)

sorry-gotta go- will look here and critical views tonight. Nancy Nancy Sculerati MD 14:11, 21 March 2007 (CDT)

removed notice

I removed the notice because I need to finish this revision. I understand now, better, what is meant by neutrality- and that has to be in one article, and not balanced between articles. I just want to put in the history that led up to the AMA's failed attempt to rout chiropractic so it is understood that, no matter how much some may have been motivated by business ethics, BJ Palmer and chiropractic's public announcements against the polio vaccine, during the 50's among other things, also led to the rejection of chiropractic as "quacks" by mainstream American medicine, and the AMA's stance in the 60's and 70's. Please let me finish it, and then go over. thank you, Nancy Nancy Sculerati MD 13:23, 22 March 2007 (CDT)

Finished revision

Please look and read through entire article. I tried to impart a narrative flow, and added what I felt was needed balance. Perhaps- unless I've tipped things too far or made mistakes in the prose, we can approve this version. Please check it. I just tried to put objections in places where I had not before because I thought that sympathy to the title theme was an overiding consideration. I tried to be fair and even complimentary overall. Also- please look here [12] I think one of these might be nice for the section that mentions patent medicines- do you think any are alright as far as copyright? (Matt-your leading picture is great. Nancy Nancy Sculerati MD 18:30, 22 March 2007 (CDT)

Nancy, your history of polio and BJ is simply a work of art! Such a great addition and explains so much about why the AMA feels the way it does. I don't think chiropractors are even aware of this. We can't stop there though. Keep in mind that BJ was not liked among chiropractors either. There were many years of hard fought battles between straights and mixers (Chiropractic History for "my" version of the mixer/straight controversy). It was the NCA/ACA that finally took the power from his hands transformed chiropractic beginning in the late 50s and early 60s witht the eventual formation of the CCE. Maybe it was the polio controversy that broke the back (no pun intended) of BJs support - I don't know. The improved education standards that were based in science started then and were hard fought within the profession by mixers and straights. It was the Mixers that were able to eventually closed the dozens of shabby chiropractic schools and based the education in science. My point is that the chiropractic that you tend to like to write about is BJ's chiropractic. It doesn't exist anymore. When I went to school in 1980, there was little mention of DD or BJ other than DD discovered it and BJ developed it. Our training was based in science and we did learn medical examination and diagnosis. I am sure that students today are even more efficient. I know you don't trust our education, and I don't blame you, but we can't describe today's chiropractic based according to BJ's philosophy. Can you help me do that? --Matt Innis (Talk) 21:32, 22 March 2007 (CDT)

Also, I do like most of the lead and most of the rest, but did not make any changes because I wanted to read the whole thing through (which was quite enjoyable). There were some spots that I think need collaboration. --Matt Innis (Talk) 21:35, 22 March 2007 (CDT)

Added a final para, but perhaps it should be in the Critical Views article instead. I think it is worth noting that timely access to appropriate care also has two sides to it.Gareth Leng 08:12, 23 March 2007 (CDT) On the undergraduate science curriculum, Coulter I et al. (1998) A comparative study of chiropractic and medical education. Altern Ther Health Med. 4:64-75 PMID 9737032 compares the chiropractic curriculum in basic science with the medical curriculum. Gareth Leng 08:12, 23 March 2007 (CDT)

OK Matt, Nancy, take a look at my changes please and see if they meet the problems Matt has raised, i.e. that chiropractic has moved on since BJ. I also cut Nancy's sentence about medicine being based on biology - certainly BJ thought that in his time chiropractic was at the forefront of science and biology.

I also think that science had rather little impact on medicine until the middle of the 20th century; before then I'm not sure that claims for its scientific basis had much force, except for the acceptance of the germ theory, and I'm not sure how much this effect had on its practise - after all Hahnemann the founder of homeopathy was long advocating sensible public health measures in the control of disease.Gareth Leng 08:33, 23 March 2007 (CDT)

Yes, guys, this is coming together beautifully and I am quite sure there is nothing else like it anywhere. I will make an attempt to add some of the BJ controversy from within the profession to help differentiate the two factions of chiropractic and how the ACA formed. Our problem is going to be space again, but I think we need to get this down before we lose our train of thought. --Matt Innis (Talk) 09:03, 23 March 2007 (CDT)

More images - Check these possibilities out: [13] [14] [15] both from [16]Gareth Leng 09:09, 23 March 2007 (CDT)

and [17] and [18]Gareth Leng 09:26, 23 March 2007 (CDT)

I love the quack doctor- lady doctor etc. poster, and although the black and white poster is nice-the color NIH poster of the spinal nerves is gorgeous. You know, while reading BJ's green books on line, I came across this statement where he claimed his father was only untruthful about one thing- that it was the axis he adjusted on the deaf janitor rather than T4, because of the critics argument that nerves around T4 could have no effect on hearing. Of course the course of VIII cranial nerve is entirely within the skull-posterior fossa, and even the innervation of the tensor tympani and stapedius-which might have a minor effect on hearing, come out the stylomastoid foramen. I only mention this since there is so much emphasis on that whole deaf janitor episode in the article (I think twice explained). Being the incredible lady that I am, I didn't bring the hammer of Otology down on it, maybe it deserves a mention, or maybe the deaf janitor's "cure" deserves less of the spotlight. You decide. Further, I want to up our byte limit on this. We should be concise, but cutting out ideas and limiting ourselves to only one picture is not in the best interest of the article. Nancy Sculerati MD 09:35, 23 March 2007 (CDT)

OK, how about you Matt? I agree that more pics will be good and I like both those images and on length I think brief is better than boring, but better long than wrong. It is interesting that as Nancy says, one of the few places in the body not inervated by spinal nerves is the ear :). However although it was where chiropractic started, I've never heard chiro since mentioned as a possible cure for deafness.Gareth Leng 10:05, 23 March 2007 (CDT)

The hearing part of the ear-the outer ear is innervated mostly by spinal nerves-the cochlea and the ossicular chain mechanism is not. A hard slap on the back could still give a sudden 60 dB improvement in hearing though- by dislodging impacted earwax! If even a pinhole was now open in the ear canal, and no obvious wax came out, that would be enough to do it. Nancy Sculerati MD 10:11, 23 March 2007 (CDT)

There is no direct nerve as far as I know. Nobody goes there anymore, and probably for good reason. And yes, you better believe a lot of deaf people have been adjusted since! Whether it happened or not, I have no idea how we could ever know. If we ask that too many times, it goes back to "Innate Intelligence". Though I suppose there is some chance of an autonomic response from the cervical or thoracic ganglion, but even then it is once in a lifetime if it did happen. Let me take a quick look at the pictures, be right back. --Matt Innis (Talk) 11:13, 23 March 2007 (CDT)

PICS

HECK NO!!! :) Those pictures are gross:0 The quack doctor one looks too much like me! That's the last thing I want to see when I read this:) Lets keep looking! --Matt Innis (Talk) 11:20, 23 March 2007 (CDT)

OK..the History article then? We might like to see you after allGareth Leng 12:03, 23 March 2007 (CDT)

I have to run for a little while, I'll get back to this tonight. I might be able to stop back a couple times, but life getting in the way right now;) Keep going!!! --Matt Innis (Talk) 11:35, 23 March 2007 (CDT)

I moved the Palmer College pic to the Chiropractic Education article to make room for the cartoon, (and because I thought that this article deserves something more exciting)... we're looking....Gareth Leng 12:03, 23 March 2007 (CDT)

Good move on the Palmer pic, what about the patent medicines?[ [19]] Like: Gold_Cure.png‎ (584 × 600 pixel, file size: 84 KB, MIME type: image/png) Or is copyright a problem? Nancy Sculerati MD 14:58, 23 March 2007 (CDT)

HA! Did you see this one? You know that Kellogg was a believer of this. --Matt Innis (Talk) 22:47, 23 March 2007 (CDT)

I like the gold one. I'll put it in the patent medicine part. --Matt Innis (Talk) 22:47, 23 March 2007 (CDT)

recent history

It's really good to bring that more recent chiropractic history in Matt, could you just explain the UXX (I forgot the letter) is-full name, and get the 1970's stuff out from being mixed in. You are adding another important piece of the puzzle. Nancy Sculerati MD 09:04, 24 March 2007 (CDT)

Sure, I do have to get some yard work done!!! It is spring here and my grass and flowerbeds are out of control:) So much to do - so little time!!! I'll take as many breaks as I can get away with and fill in some spots. Meanwhile, feel free to add your stylish touches, too. --Matt Innis (Talk) 09:22, 24 March 2007 (CDT)

Deafness

I don't think anybody doubts that DD Palmer thought he had fixed the man's hearing, or that there was some physical interaction between the two and the man then said he heard better. I don't think you have to change it. That sentence could even start: By accident or design - just so we cut words without cutting either meaning or flow. I assure you there are people who believe that chiropractic must be a cure for deafness, because they know that story. That's why I think the line about the agreement between chiropractors and physicians that it is not is important. Or else, the whole story can be de-emphasized, as really-how important is it? Nancy Sculerati MD 11:52, 24 March 2007 (CDT)

Okay, Let's put the deafness "disclaimer" a little closer to the story. I'll try something and you see what you think. --Matt Innis (Talk) 12:38, 24 March 2007 (CDT)

I saw your changes and think they will work. Check mine and see what you think. This way we can leave the deafness in which certainly explains why this peaks some interest. I do remember reading that he said no-one had ever been able to match his forst adjustment. It may be a stretch to use it against him;) Does it work? --Matt Innis (Talk) 12:51, 24 March 2007 (CDT)

Cleanup up some, added some. Have to go for about an hour. I know this has to be consolidated, pictures, etc, but we're getting there - I think:) Keep going! --Matt Innis (Talk) 14:09, 24 March 2007 (CDT)

Move to approve

I think so too. I just moved things so that they are chronologic, or more so, and if we can get the pictures in and get Gareth to read through I think we can approve. It's not perfect, but it is so much better than the approved version that it would be a shame to launch with the other one instead of this one. The bytes here are not wasted, we cannot convey the profession reasonably in less. This article is not useable in a real-world sense if its too abbreviated. It's not like Biology, that is just an introduction to a field. A person who goes to a chiropractor cannot get the real sense of what a chiropractor is without this article as it more or less stands-cut it too thin and it loses its ability to explain. Nancy Sculerati MD 14:53, 24 March 2007 (CDT)

Nancy! I think I might be done!? How are you? I do wish you would go through and add your style to my stuff:) I have added a jail picture and their is another one with patients holding signs wanting their doctors back, but I'm not sure if it will go over the top.[20] I'm ready to work on the other pictures now. I think I'm finished with the text - assuming you and Gareth will work your majic. By the way - your last paragraph was another work of art. Thank you. --Matt Innis (Talk) 18:34, 24 March 2007 (CDT)

I'm going to put the tag back on. We can copy edit more from here but I think the major work is done, right? (Other than pictures) --Matt Innis (Talk) 19:28, 24 March 2007 (CDT)

agree Nancy Sculerati MD 19:40, 24 March 2007 (CDT)

Hey, this is the copyright info from the NIH NLM website [21]. I'm not sure what to think. Anybody seen anything else while I am waiting to hear? --Matt Innis (Talk) 22:52, 24 March 2007 (CDT)

May be more bad picture news. Our top picture may be copyrighted, too. Bummer. --Matt Innis (Talk) 00:28, 25 March 2007 (CDT)

You have to check the source of the actual picture. Nancy Sculerati MD 05:47, 25 March 2007 (CDT)

Also-please look at changes made in the draft, I would like to incorporate those in approved version-like the change in the picture caption of the jailed DC (if we can still use the picture, that is.)Nancy Sculerati MD 06:02, 25 March 2007 (CDT)

I'm still looking into the pictures. Keep your fingers crossed. Also, we can put our last version in when we are done. I woke up thinking about some things, too, but we can approve and then start on a new version that we don't have to re-approve for awhile as we go work on other things. --Matt Innis (Talk) 07:52, 25 March 2007 (CDT)

Did a copy edit, nothing controversial in my edits (or so I think and hope). I'm happyGareth Leng 03:58, 26 March 2007 (CDT)

Made my way through one more time, made a few minor changes, I think, and some copy edits. I'm still happy. --Matt Innis (Talk) 07:50, 27 March 2007 (CDT)

Also, have been in touch with Joseph Keating who is thrilled with the fact that we appreciated his work and has forwarded my comments to his colleagues. He has given me some insight as to ownership of copyrights on the images in the archives and it looks good so far. The ACA has released all the rights to images in any of the NCA archives, so I'll be looking through some of those. Keep your fingers crossed! --Matt Innis (Talk) 07:50, 27 March 2007 (CDT)

It's not clear to me that Nancy is ready for the approval of this, so I wrote her requesting comment here pending my placement of the Approved template. Stephen Ewen 21:12, 27 March 2007 (CDT)

I agree,thanks Stephen. --Matt Innis (Talk) 21:20, 27 March 2007 (CDT)

I went through and made some minor changes, primarily wording for clarity. Of course if it seems more clear to me, it might seem wrong to you Matt-so go thorugh. But if you can live with these minor changes I am happy to approve the version I just edited.I am so sorry to have lost our leading picture, it was wonderful. Nancy Sculerati 10:17, 28 March 2007 (CDT)

Looks good, I did change "old school" to "established straight school" and changed the legend in the ACC table. If you're okay with that, we're done here. --Matt Innis (Talk) 12:35, 28 March 2007 (CDT)

Okay, took out the image and updated the version ToApprove. --Matt Innis (Talk) 13:33, 28 March 2007 (CDT)

False dichotomy?

I just changed the text on the ACC Chiropractic/Medical Management Model figure since it was impossible to read it without looking at the blowup. When doing it I noted that health promotion was at the far right in the chiro only section. This seems to be wrong. Every time I see a doctor they prescribe healthy living and have leaflets on this all over their office. For me, this brings into question the whole health/disease dichotomy asserted by the figure, although, I admit, I know next to nothing on this topic. Chris Day (Talk) 10:04, 28 March 2007 (CDT)

Thanks Chris. I never looked at the blow-up, and health promotion is not chiro only, of course. Nancy Sculerati 10:19, 28 March 2007 (CDT)

I re-labeled it to try and show it is the ACC's vision. I'm seeing these as treatments rather than education, brochures, etc. In other words, Chiropractic would use maintenance care or well care treatments for otherwise healthy people that Medicine would not treat. I think the major point of the picture is to show the potential for collaboration between the two professions. --Matt Innis (Talk) 12:21, 28 March 2007 (CDT)

Wikipedia credits

The following 3 sentences (out of about 180...) appear to come from Wikipedia. Maybe it is ridiculous, but what about some nice rewording to make clear that no WP-credit is needed? Here it goes:

• The AMA lost its appeal to the Supreme Court, and had to allow its members to collaborate with DCs.
• A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient.
• Physicians may also ethically teach in recognized schools of chiropractic.

--AlekStos 15:15, 28 March 2007 (CDT)

Many thanks for sharp eyes Alek. The second two sentences are direct quotes from the AMA so WP needs no credit there, the other I've changed. Gareth Leng 04:04, 29 March 2007 (CDT)