Medicandus

Medicandus

Concerns about chiros are about quality and safety, not some phoney turf war

This weekend saw another exchange of views between chiropractors, the AMA and the Friends of Science in Medicine. It was set off by a number of stories by Amy Corderoy, the Health Editor at the Sydney Morning Herald, here and here and here.

In a nutshell, the issue was that government funding of chiropractic care for children under 14 was reported to have risen by 185% in four years. This prompted the AMA and others to question the advisability of this spending given the poor scientific evidence base for such care, as well as the potential for harm to children given that no clear benefit has been established. A particularly worrying point was the apparent tacit support of the Chiropractic Board of Australia for professional development courses run by opponents of mass immunisation.

The response from the Chiropractors' Association of Australia (CAA) can be found here. Predictably enough, the CAA has chosen to cast chiropractors as the hapless victims of a league of overpaid bullies representing unnamed but powerful medical interests.

What concerns me? The back story…

What particularly concerns me is the near-complete avoidance of any plausible effort to address the concerns raised by the AMA and FSM. The CAA release simply dismisses them as “purported concerns” and claims there is no evidence presented to back them up. According to one of the SMH articles,

National director of the Chiropractors Association of Australia Tony Croke said in the past 40 years no serious adverse health consequences of chiropractic had been recorded in a child.

Well, I have some news for CAA. It took me about a minute to find it on PubMed.

Here is one case. And here is another. Here is a whole systematic review of serious adverse events in children receiving chiropractic care, including some fatalities.

How about some more evidence to support the concerns raised in the SMH that chiropractic continuing professional development (professional education or CPD) actively supports presenters with an anti-vaccination agenda?

Here is a flyer for Tim O'Shea, a well-known antivax chiropractor. As you can see, it was advertised as “CAA Accredited”. Nimrod Weiner, the CAA’s current NSW Branch Secretary has regularly presented a “vaccination information” seminar that is packed with misleading inaccuracies. Chiropractors remain by far the largest professional group supporting the Australian Vaccination Network.

A paper presented at a major international chiropractic conference gives more cause for concern about the teaching of attitudes to immunisation in chiropractic training. (the abstract concerned is on page 63). This Canadian study demonstrated that positive attitudes to vaccination declined from 60% among first-year students (which is worrying enough you might think) to under 40% by fourth year and graduation. What is it about going to train as a chiropractor that could convince a third of those with pro-vaccination attitudes to drop their support?

Denial of public health responsibilities is unacceptable

If the CAA figure of 215,000 weekly visits to chiropractors is to be believed, the antivax activities of chiropractors may be creating a huge reservoir of underimmunised Australians. Preventable diseases spread quickly where such reservoir populations exist. For an AHPRA Board to tolerate the creation of such a massive threat to public health is frankly alarming. It’s not that hard to join these dots, yet the Chiropractic Board of Australia (CBA) seems unable to understand or accept that as a regulated profession, chiropractic shares the responsibility for maintaining public health.

Resorting to the PR technique of pretending to know nothing about immunisation isn’t good enough. The CBA has released a position statement advising that,

Patients have the right to make their own health decisions, but they need to be appropriately informed about the benefits and the risks to both the individual and the broader community associated with their health decisions.

Practitioners may often be asked to provide information not directly relevant to their competency or the scope of their practice; in such cases patients should be referred to someone with sufficient expertise in that field to have their questions or concerns addressed.

Advice about vaccination is not typically within the usual area of practice for a chiropractor. Current evidence indicates that preventative measures such as vaccination are a cost and clinically effective public health procedure for certain viral and microbial diseases.

The Board would clearly seem to have a direct and insoluble conflict of opinion with the likes of Tim O'Shea and the (soon to be renamed) Australian Vaccination Network, who both provide CPD resources to chiropractors.

Restoring credibility

In the interest of being seen as constructive, I’ll give some free advice to the CBA and CAA. Following these suggestions would go some way towards restoring some badly needed credibility for both organisations.

  1. CAA should stop pretending that children have never been harmed by chiropractors, and should publicly retract their assurances to the contrary. After all, I’ve already pointed them towards some published evidence with a brief online search. I’m sure there’s probably more to find.

  2. CBA should decline to acknowledge the CPD hours of those who have attended events which have a clear antivax agenda. It’s the least they could do now it is clear that CPD credit shouldn’t have been given to events which conflict with the Board’s clear directives.

  3. Both CAA and CBA should acknowledge that chiropractors have a public health duty to participate in immunisation and recommend it to the general public. They should do this to prevent the creation of a large community who all are in contact with each other and have inadequate herd immunity.

  4. CAA and CBA should encourage chiropractors to be educated about immunisation if they are of the opinion that it is not a particular area of expertise. Instead of giving their imprimatur to vaccine deniers, they could award CPD hours for undertaking online courses such as this one from the University of Pennsylvania.

  5. Both organisations should acknowledge that the scientific rationale for treating children with chiropractic methods is substandard. The usual course for a responsible profession is that such treatments should be considered experimental, and not offered widely until compelling evidence of their safety and effectiveness exists. Neither should endorse treatment for children with the current state of the literature, since harm can exist, and benefits are not established.

This isn’t a turf war

It is quite clear that this is not a turf war. It never was. With just over 4300 registered chiropractors compared to over 91,000 registered doctors I don’t think we’ll be seeing doctors lining up at Centrelink due to chiropractors taking over any time soon.

Despite the protestations of CAA, this is very much a quality and safety issue. In large part it has been brought about by the ongoing denial of chiropractors that they have such responsibilities.

People like myself, the AMA, FSM and many others expect a lot of an AHPRA-regulated profession. We are not picking on chiros as much as we are holding them to the same standards we would expect of any health profession. I’m sure many rank-and-file chiropractors would welcome decisive leadership from the largest of their professional bodies to put these issues to rest.