Trick or treatment is a rebuttal by Dr Barrie Lewis to the book by Dr Simon Singh and Prof Edzard Ernst.
Dr Singh is not a medical doctor but a science writer with a Ph.D. in particle physics. He has been a producer for BBC science programmes and written three books, one of which, Big Bang, became a New York Times bestseller.
Prof Ernst is (was) in the chair of Complementary health care at the University of Exeter in England. Having trained at a homeopathic hospital in Germany he has, after a long and distinguished career, become known as the "the scourge of alternative medicine".
"A problem well stated is a problem half solved."
Charles F. Kettering
Drs Simon Singh and Edzard Ernst have written a compelling book, Trick or Treatment, which has been enthusiastically and uncritically, in my opinion, received by the journalistic and medical community. On the surface, they have written a convincing and persuasive evaluation of alternative and complementary health care.
But beneath the surface… just how well have they stated the "the problem" of Complementary and Alternative Medicine? Just how "sound", balanced and fair is their advice?
"Physicians should recommend Trick or Treatment to their patients, and it will help health practitioners provide patients with sound advice."
New England Journal of Medicine
SCIENCE Singh and Ernst make an unambiguous statement that all health care needs to be lifted out of the domain of anecdote and opinion, and subjected thoroughly to scientific testing as to whether the claims made are valid.
I cannot see any objective doctor, mainline, complementary or alternative disagreeing, though some of health care cannot be easily subjected to scientific formulation:
Fifty percent of a large sample of physicians admit to the regular prescription of placebos; placebos aren't scientific medicine, though proven to be more effective than no treatment at all; but how would it stand up to the much vaunted “evidence based scientific medicine” that the authors speak so highly of?
Secondly, as the Peter Principle man stated, some of health care is so complex that you have to be highly intelligent and well-informed just to be UNdecided about it...
But on the whole, I have to agree with the recommendations in Trick or Treatment that the chiropractic profession should not shy away from thorough scientific evaluations of our claims regarding the benefit of chiropractic care. Just as in medicine there will be contradictions ... recently two large prostate research programmes in the PCPT found that certain drugs commonly used for BPH reduced the overall rate of prostate cacner but increased the rate of aggressive prostate cancer...
Trick or Treatment REBUTTAL They are not afraid to evaluate some
of medicine’s murky past. Their description of how four of America’s
most senior doctor’s drained half of George Washington’s blood in less
than a day, “effectively killing the former President by needlessly
bleeding him to death” (p23) makes for sober reading. But their
assessment of the current status of medical iatrogenic illness is
IATROGENIC ILLNESS ... 250,000 American deaths per year.
Likewise, the tortuous discovery of the cure for scurvy is beautifully and objectively handled; Dr James Lind’s scientific methods brought him to the brink of saving literally millions of lives, only to see all dashed by the vagaries of food processing of citrus. Orange juice is not the same as OJ.
Their unequivocal support for “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” is noble, and it’s the foolish chiropractor who won’t allow his theories to be tested in an impartial way.
The story of how two doctors, both knighted, Austin Hill and Richard Doll finally proved beyond all doubt the smoking-lung cancer link makes gripping reading. It's the story of intuition, persistence and solid research. Not that this generation seems to have taken much notice...
Of particular significance for chiropractors is that smoking is the biggest complicating factor in the treatment of lower back pain.
Chiropractors in the United Kingdom, at a rough assessment, would give about 10 million cervical manipulations per year. Of course many other professions also do manipulation, not to mention those done by lay manipulators.
Edzard Ernst reports in Trick or Treatment, after exhaustive research with the Association of British Neurologists, identified nine cases of stroke in one year after cervical spine manipulation. Not all of course, or even a majority of these cases can be laid at the door of the chiropractic profession. Physiotherapists, physical therapists, general practitioners, orthopaedic surgeons... even your corner Turkish barber all regularly do neck manipulation.
Aside: It's one of the serious difficulties I have with this book. "Edzard Ernst asked members of the Association of British neurologist to report cases of neurological complications that had occurred within twenty-four hours of neck manipulation ... nine strokes, over the course of one year." (p217) Using the innuendo typical of this book, all nine cases are attributed to Chiropractic manipulation yet Ernst carefully omits the number of these cases that occurred after a chiropractic consultation.
But, in any case, these statistics are roughly in line with the Chiropractic professions own exhaustive research. STROKE CHIROPRACTIC appears to occur in approximately one per one-two million manipulations.
In Ernst's own words,
"This is a remarkably small risk, roughly one in a million... "
Prof Edzard Ernzt
Ernst continues to blot his own copy book by stating "experts suspect that the vast majority of incidents go unreported..." - after telling his readers that after and "exhaustive study" they could locate just nine cases in one year. And that works out at 1/ 1,000,000 cervical spine manipulations, of which perhaps a half? can be attributed to the chiropractic profession.
… there is much positive about this book. Sadly, for such distinguished writers, much more that is negative...
Nevertheless, despite the positive, my overwhelming impression is that Trick or Treatment was written with a nefarious agenda. Much of it, with regard to chiropractic in any case, is neither conscientious nor judicious, nor fair, nor transparent. They carefully seek out the soft underbelly of chiropractic:
Our theories of more than a century ago are still attributed to modern day chiropractic;
They quote Paracesus from the Sixteenth century, but I have the overwhelming impression that this book was not written with “an open mind”. It is neither “transparent nor fair” and was written to achieve a specific result: the denigration of complementary and alternative health care.
"The art of healing comes from nature and not from the physician. Therefore, the physician must start from nature with an open mind."
Paracelsus (1494-1541) p233
Trick or Treatment REBUTTAL Singh and Ernst correctly distinguish between the so-called CAM professions, those that are used either alongside (complementary) or instead of (alternate) conventional healthcare. And then by sleight of hand, because it’s a “lengthy and clumsy phrase” consign chiropractic to alternate therapy.
Chiropractic, the third largest healing profession after medicine and dentistry, has worked hard to become widely recognised as complementary to medicine. A huge amount of scientific research has been done validating the effectiveness of Chiropractic.
As they themselves grudgingly admit in Trick or Treatment: "chiropractors have become part of the medical mainstream in that they are licensed in all fifty US states, and they also have legal recognition in many other countries. For example, chiropractors in the United Kingdom are regulated by statute, which means they have a similar standing to that of doctors and nurses.”
But they cunningly, because of a "lengthy and clumsy phrase” (why don’t they use "CAM" like the rest of the world?) relegate chiropractic to a level alongside homeopathy, crystal therapy, magnet therapy, neural therapy, reflexology, spiritual therapy…
Has Professor Ernst, in the chair of Complementary health care at the University of Exeter, just done himself out of a job? Does Complementary Medicine not exist?
Few things detract more from this book than the use of anecdotes. It's particularly galling coming from men who espouse the scientific method and set themselves up as doyens of evidence-based medicine. Of all people these two men should know better.
Anecdotes do nothing for "establishing the truth in relation is alternative medicine", (p16) and are a far cry from the evidence-based medicine they champion. Rather, they are blatant smear tactics. Trick or Treatment is littered with such anecdotes.
I could write a book telling you about
Yes, I too could go on and on with anecdotes about the soft underbelly of medicine, but scientific medicine denies that anecdotes, scientifically speaking carry any water at all. Not a drop! Those stories above are scientifically worthless. It's shocking that men of Singh and Ernst's calibre use such smeer tactics to frighten the public. Even worse, that those who do reviews from respected journals like NEJM should also be hoodwinked by these two... I'll just call them men!
Singh and Ernst display their extreme ignorance of chiropractic by suggesting that a chiropractic adjustment is analogous to extending the wrist fully and then applying an “additional short rapid thrust on the fully extended hand, thus bending it down even further by a small amount.” (p189) One would have thought that, writing so authoritatively about chiropractic, that they would have availed themselves of one of the most basic tenets of a chiropractic adjustment, namely distraction. They could not have found a worse analogy than a forcible wrist extension to describe a chiropractic manipulation.
"Rather sit and look like a fool; open your mouth and you may remove all doubts."
my father, Dr Dick Lewis DC
Dr Ernst and another colleague cooperated to do a “systematic review of systematic reviews of spinal manipulation” and conclude “all in all, the evidence was insubstantial.” Clearly several of the reviews were of spinal manipulation done by other than chiropractors.
I'm still working on this one.
Writing about the AMA’s “Committee on Quackery” in 1963, S&E state that medicine’s underlying difficulty with chiropractic was “chiropractors’ denial that bacteria and viruses cause many diseases, and their conviction that realigning a patient’s spine could cure EVERY ailment.” (p200) Every healing profession goes through stages of enthusiastic but ultimately unfounded belief in a particular therapy. S&E themselves describe this aptly in regard the letting of blood, the use of drugs that caused Benjamin Franklyn to remark that ‘all drug doctors are quacks’, the use of ACTH in preventing blindness of premature babies…
Chiropractic is no different. Early chiropractic pioneers too had some very quaint, and even dangerous ideas. Yet, in 1963 I doubt there was one chiropractor on the planet Earth who denied the role of viruses and bacteria in disease, and who thought s/he could cure EVERY illness with spinal manipulation. And, even if there was a small fringe of fanatics, S&E admit that at that time medical doctors themselves were averse to the scientific method, preferring to practise according to their own experiences.
And to martyr today’s chiropractors because of the belief of those a century ago is palpably absurd. At that time, the standard medical practice was to treat typhoid by wrapping the patient in a sheet soaked in high quality whiskey. Leaches were still in use…
“The knowledge that vaccines and antibiotics are safe…” (p50). All vaccines are patently not safe, and that’s not just my opinion, but the way the authors make this bland statement gives us an idea of their blinkered mindset. Research by the Centre for Disease Control showed that the rate of Guillain Barr syndrome in the USA doubled after the 1976 Swine Flu vaccination. This was confirmed after the Institute of Medicine (IOM) conducted a thorough scientific review of the issue in 2003. Of anecdotal interest only, two years ago three healthy babies in the Netherlands died within 10 days of receiving a pneumococcus vaccination. The programme was immediately suspended.
“It is clear that the vast majority of chiropractors will not encourage immunization.” Singh and Ernst make this bald statement on p226 of Trick or Treatment, based on a mere sixteen responses to a questionnaire that they sent to a group of British chiropractors. On the basis of that survey they conclude that “the vast majority of chiropractors…” All 100,000 of them? And this after they had already been taken to task by their very own ethics committee for their questionable methods and conclusions. (p226)
The Institute of Child Health in London reports in the New England Journal of Medicine, that “one child a week is being made permanently deaf by treatment with antibiotics”. Are antibiotics unquestionably safe as assumed by the Singh and Ernst? Or do the authors have an agenda, making bald statements about the dangers of CAM treatment and quietly making out that medicine is perfectly safe? And there is absolutely no comment about the 250,000 people who die every year in the USA from iatrogenic disease?
I don’t believe the chiropractic profession has a policy on vaccinations though individual chiropractors have strong reservations. My own opinion, for what it’s worth, is that the benefit outweighs the dangers in vaccination against serious diseases like polio. Against the flu? Positively foolhardy in my opinion, having observed the number of patients over the years who have become seriously ill with either the flu and even one who developed Guillain Barr within a week of having a flu shot.
But this Trick or Treatment REBUTTAL is not about the merits and demerits of vaccines and antibiotics. It’s about the way Drs Singh and Ernst make statements about health care that are blantently untrue and are neither fair nor transparent.
INFORMED CONSENT Trick or Treatment REBUTTAL … “they often fail to warn patients of the potential risks of their treatment.” (p218) This I suspect is patently true despite the fact that it is mandatory in the Code of Chiropractic Practice in many countries, and the reasons are quite obvious:
A new patient arrives with a condition, say a cervical facet syndrome, that I know will respond to chiropractic because I have treated thousands of similar cases; provided the patient is able to relax sufficiently for me to manipulate the fixated facet joint.
Said patient arrives in a positive frame of mind, having been referred by a friend or relative who had a similar problem that resolved with chiropractic care.
“Mrs Jones, I can give you a reasonable assurance that we can treat this painful syndrome successfully. Frankly, it’s the sort of condition that I treat many times every day, and whilst it can be difficult occasionally if you’ve had old injury like a whiplash, I’m not expecting problems. But there’s a potential problem. You could have a stroke after the treatment. ”
Gone is the positive frame of mind and the healthy healing environment. Gone is the patient who is able to relax sufficiently to enable a gentle cervical spine manipulation. Probably a third of patients will leave even before the treatment.
So, because one in several million manipulations may cause a stroke, millions of people with a painful facet conditions are denied treatment.
It’s a serious dilemma, and certainly one that ought to be brought out into the open, and discussed fully by the profession.
But this is not about the merits and demerits of informed consent. It’s about how fair and transparent are Singh are Ernst in their serious criticism of the chiropractic profession in Trick or Treatment.
My question: Have Singh & Ernst done any research on whether medical doctors warn their patients about the
Do they, Dr Ernst and Singh? Do the medical doctors whom you so heavily favour, despite the facts, the scientific facts, warn their patients of “the potential risks of their treatment?” Or, don’t you know, and frankly “don’t confuse me with the facts, my mind is already made up?”
"(Medical) Doctors in the 1950s preferred to rely on what they had seen with their own eyes ... as opposed to the evidence from research trials... (p187)
“Not only is spinal manipulation useless in terms of treating, for example, asthma, …” (p218)
Repeated, and I mean repeatedly, Singh and Ernst criticise the chiropractic profession for treating non-musculoskeletal conditions and almost invariably asthma is brought up. The fact of the matter is that I don’t know one single chiropractor who claims to treat asthma. I’ve treated many asthmatics over the years for a variety of conditions, and I don’t recall one who said the treatment helped his/her asthma. I expect there are fringe chiropractors who make such claims; either they know some tricks that I don’t, or they deliberately mislead their patients, hoping to make a fast buck not realising that after the failed treatment their names will be bad-mouthed all over town.
But this is about fairness and transparency. Where do you get your facts from, S&E, and just how many chiropractors claim to successfully treat asthma? Did you, on the basis of emails to 16 chiropractors, make the assumption that the vast majority of chiropractors claim to treat asthma?
Strange things do happen in the practice but I don’t believe that more than a handful of fringe chiropractors would claim that they can treat asthma successfully, help infertile women fall pregnant, menstrual cramps…
Whatever the research, I personally have had great success in the treatment of infantile colic… as Carl Sagan was want to say: "Absence of proof is not the same as proof of absence."
And again, “Why should manipulating the spine alleviate asthma?” (239), the same boring old rhetoric. In fact, I don’t believe it does, only a lunatic fringe possibly do, but if S&E were writing their book 300 years ago, I can hear them categorically stating : “Why should lemons alleviate scurvy”? As the French say, there are none so blind as those who WILL not see.
"… traditional ambitions of … chiropractic therapy – manipulating the spine or bones in general can cure everything …” I wonder how S&E would react if I was to write of the “traditional ambitions of medical therapy – letting of blood in general, the use of leeches, can cure everything…”
Curing everything by manipulating the spine and the use of leeches belong firmly in the previous millennium, Drs Singh and Ernst; perhaps you didn’t know that! I know I can speak for the chiropractic profession with all confidence. Medicine, well there I’m not so sure, you mention that medicine is still using leaches! Hence my visit every two months to visit the vampires!
Really! It’s a long, long time since chiropractors believed they could cure everything, even anything, by manipulating the spine.
One thing I have to agree with Drs Singh and Ernst: "Even if your problem relates to your lower back, it is still worth stressing that your neck should not be touched…” One needs to have sound reasons for manipulating any joint, and the routine manipulation of every patient’s neck regardless of the condition, I personally think extremely foolhardy. Whilst a stroke is extremely rare, the next adjustment just could be the one in a million…
Trick or Treatment REBUTTAL
The authors of Trick or Treatment make out numerous times in their book that chiropractic is far more expensive than medicine; furthermore they suggest that greed is often the motive behind chiropractic, and that the pharmaceutical industry is in the business to “mass produce drugs at low cost."
Firstly, E&S clearly have never owned an X-ray unit, as I have. It’s a financial hole in the ground. Never was I more pleased than the day Medicine was forced by the American Supreme Court to alter their stance that it was “unethical” to cooperate with chiropractors in any way. Wilk vs AMA ...
Radiologists by sheer volume are able to update their equipment regularly, by reading X-rays day in and day out are better than the average chiropractor when it comes to diagnosing pathology, and it saved me a packet when I managed to sell my X-ray unit to a local vet, and obtain better X-rays of my patients from the local radiologists.
As to whether the pharmaceutical industry is in the business to produce drugs at low cost, the most absurd statement in the whole book, in my opinion, I’ll leave it to you the reader to decide. Well, produce them at a low cost, and sell them at an exorbitant profit. It was only a year after Trick or Treatment was published that Pfizer were compelled to pay a $2.3 billion settlement for Bextra fraud. $2.3 BILLION! PFIZER BEXTRA FRAUD ....
"Education is the ability to listen to almost anything without losing your temper or your self-confidence."
Just take the story of beta-sitosterol, a phytosterol found in many foods. Simply eating an avocado per day provides all the protection of beta-sitosterol against raised cholesterol, non-bacterial prostatitis and benign prostatic hypertrophy, but the pharmaceutical industry would rather that we bought their product at 10x the price of an avocado with all the avo's other benefits. Worse, the synthetically made drug has numerous side-effects, including an increased rate of aggressive prostate cancer, none of which pertain to the naturally occuring product.
Whilst there is no doubt that Singh and Ernst have a point here, a good point to knock Chiropractic, one we should take note of, it's galling that they have the temerity to point fingers when, in medicine's own backyard...
"Unfortunately, clinicians are not using adverse event reporting systems adequately. I think it's fair to say that many physicians have no idea how to even use the system, and this is a problem."
Dr. E. Fraifeld, president of the American Academy of Pain Medicine
Having said that, both Chiropractic and Medicine have the responsibility to report adverse effects to their professional bodies. The problem, whether medical or chiropractic, doctors are afraid of being sued, found guilty of unprofessional conduct... it's easier to hope it will just go away. And usually it does.
"…which herbal medicines work … which are dangerous and perhaps even lethal.” (p241)
Whilst it’s not part of my portfolio to defend herbal medicine, I feel it pertinent to remark that a quarter of a million (yes, read 250,000) Americans DIE every year from iatrogenic illness ... Doctor-caused disease, and the majority of these are caused by adverse reaction to medical pharmaceutical drugs. Fair and transparent? There’s not one word that I’ve read in Trick or Treatment about the lethal and dangerous drugs marketed by medicine. A QUARTER OF A MILLION AMERICANS. That’s enough good folk like you and me to fill a fair sized city. EVERY YEAR.
Regularly in Trick or Treatment the Singh and Ernst pots have the audacity to call Alternative and Complementary health care kettles black. People who live in glass houses shouldn’t throw stones. Sorry, mixed metaphors, a no-no!
It gives me for one a nauseating feeling in the pit of my stomach as S&E pontificate about “we now accept that almost every medical intervention carries a risk of side-effects.” (p249) And that “doctor and patient should agree that the likelihood and extent of the potential benefit outweigh the risk and severity of adverse side-effects.”
It’s pure speculation, I’ll admit, but I very, very, very much doubt that medicine comes close to the 25% of chiropractors who have the courage to tell their patients of the possible risks of treatment.
As a very rough guide:
80,000 American chiropractors giving 60 cervical spine manipulations per week = 500,000 manipulations per week.
= 26 million cervical manipulations per year.
At 1 stroke / 1 million manipulations = 26 strokes per year.
At 1 stroke / 5 million manipulations = 5 strokes per year.
(research suggests the figure lies somewhere between 1/ 1-5 million manipulations.)
Which ever way your look it, compared to 250,000 DEATHS every year in the USA due to medical iatrogenic disease, the chiropractic profession can afford to look disdainfully on the pronouncements of the likes of Singh and Ernst in Trick or Treatment about First, do no harm. Having said that, every clinician would agree that treating their patients with great care, doing their utmost to minimise iatrogenic illness, is vitally important.
WHY DO SMART, EDUCATED SCIENTISTS LIKE SINGH AND ERNST BELIEVE SUCH ODD THINGS?
Trick or Treatment REBUTTAL
they have “drawn upon the results of hundreds of scientific papers”
concerning Complementary and Alternative Medicine, whilst selectively ignoring the
thousands of scientific papers concerning mainline Medicine. Nowhere is
there mention of the word 'thalidomide’. Nowhere do they mention the Cox
2 NSAIDS that have been withdrawn from the market after thousands of
deaths due to heart disease. Not one word about Propoxyphene Worst drug in history ...
We believe odd things, all of us, myself included, because our contrary minds are already made up, despite the overwhelming evidence to the contrary.
Chiropractic indeed has its soft underbelly, and after thirty plus years in practice I would not begin to pretend that chiropractic is totally safe. It’s not.
But in thirty years I can look back on only three frightening reactions to 200,000 cervical manipulations, all of whom recovered completely within a few days with no lasting effects.
It’s true I’m ashamed to admit that there have been six cracked ribs, but all six recovered within a few weeks with no lasting effects. There have probably been a dozen or more hernias that have been aggravated. Perhaps even two or three dozen.
But compared to thousands and thousand of people who have been helped by chiropractic, those are a mere drop in the ocean. We chiropractors have cornered no part of the local cemetery. Nor are our charges in the main exorbitent, thought without a doubt greed has touched a segment of the chiropractic profession too.
Quite a lot of patients don’t respond as expected to chiropractic care, but that's probably because of our clinical ineptness rather than the ineffectiveness of chiropractic, but virtually none of them die.
Are chiropractors sometimes extra especially stupid? Yes, certainly, and looking back, I admit to my share. The case of Laurie Mathiason, who allegedly died after two chiropractic manipulations is a case in point.
Chiropractors are not in denial: the next cervical spine adjustment that I give could be the one in several million that causes a stroke.
But few of us are so stupid as Laurie’s chiropractor. After she reacted extremely badly to a manipulation, in contradiction of all that we know and advise, s/he manipulated Laurie again the next day. Tragically, the adverse affect of the first manipulation was trebled and she died.
I’m truly sorry for Laurie and her family, but that same chiropractor has probably helped tens of thousands of people. But in a moment of insanity, he forgot all that is sane and sensible, and manipulated her a second time.
Are there any of us who don’t have moments of insanity and stupidity? Singh and Ernst would have you believe that only chiropractors do such dumb acts, and that the hands of Medicine are lily-white. I leave you to be the judge.
Trick or treatment is a controversial evaluation of Chiropractic by Simon Singh and Edzard Ernst.
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