The Irony of Choosing Wisely

Gerard W. Clum, D.C., Life University presidential advisor and president emeritus of Life Chiropractic College West, and has served on the board of directors or as an officer of the Association of Chiropractic Colleges (ACC), the Council on Chiropractic Education (CCE), the International Chiropractors Association (ICA), the Foundation for Chiropractic Progress (F4CP), the Chiropractic Summit and the World Federation of Chiropractic (WFC).

The Choosing Wisely discussion in chiropractic as it relates to the use of x-ray has been an interesting one. I must admit I don’t understand why we seem to need to demonize each other over a difference of opinion on a subject like this. We can hold polar-opposite positions on a subject without either party needing to be evil, stupid, ill-intentioned, etc. Please do not use anything I put forward in such an ill-tempered manner.
On March 22, 2019 at the WFC/ECU Congress in Berlin, Germany there was a panel discussion on the use of imaging. One of the presenters, Michele Maiers, D.C., M.PH., Ph.D. an officer of the ACA as well as of the WFC, asserted several positions on this question that are worthy of some additional review.
Please consider:

“X-ray should not be routine for patients with acute low back pain during six weeks after onset.”

The issue: No one is asserting a need for “routine” x-rays of any kind!

“The research shows us that…imaging is a very poor predictor of outcome”

The issue: The imaging in question is not used as a predictor of the outcome of any clinical intervention. It could, however, assist in preventing an adverse outcome.

“Degenerative change is normal, it is basically ubiquitous as we age”

The issue: Degenerative change may be expected with age, but the nature and extent of the degeneration is not consistent or predictable. Most importantly, a change perceived as a function of aging does not mean that it is an inconsequential change clinically.

“…with even a moderately good clinical history and examination (it) should give you an indication that perhaps you need some additional diagnostic testing and that may or may not be plain film imaging.”

The issue: Under the recommendations of the ACA to the Choosing Wisely program, such latitude on the part of the provider is not present.

“I generally hear three challenges from chiropractors… The first thing I hear is that the evidence that we are basing these recommendations on comes from primary care, and that is completely irrelevant when we’re talking about chiropractic. We have the same patients. This is not about the profession.”

The issue: The experience of primary care is relevant, but it is incomplete when we are talking about chiropractic care. We do have many of the same patients, but this is very much about the profession as the nature of the intervention of the primary care physician (pain medication, muscle relaxants etc.) is radically different than the care of the chiropractor (spinal adjustment).

“I generally hear three challenges from chiropractors… The second thing I hear often time is that…primary care providers write a script, and they have this lower risk intervention (because) we do high velocity, low amplitude adjusting, and there’s more inherent risk…so we have to have more certainty, that we’re not exacerbating the risk for our patients.”

The issue: Primary care providers do not have a lower risk profile due to their prescription drug approach. They do, however, have a different risk profile than a chiropractor. In the interests of the patient’s well-being, each provider must address the risks inherent to their clinical response. Based on the chiropractor introducing a force as opposed to a drug the utility of an x-ray image may be different than it would be for the primary care provider.

“I (am) really reluctant to feel that HVLA is all that risky, especially if you are educated in a high-quality chiropractic program.”

The issue: The snarkiness associated with the implied criticism of some educational programs aside, HVLA in general, and in the low back pain environment is a very safe intervention, the potential for an x-ray study making it even safer exists.

“And almost most importantly, we know from the very good evidence, but just patients even having the knowledge of clinically irrelevant findings on plain film imaging hinders a recovery because they start catastrophizing, other things that have been pointed out or imaging, and it may be preventing them from engaging in activity and exercise, and work and all that helps potentially need longer term disability.”

The issue: The same imaging can relieve the patient that they do not have a cancerous situation, that there are not structural barriers to them getting better, that they can and should exercise, etc. How the findings are used and conveyed is the issue—not the finding itself in this context.
Later in the same session during a question and answer period, I was able to put a question to this speaker as follows:
Dr. Clum: “I’d like to speak to a nuanced subset of this discussion. Part of the concern in the United States, in particular, is the fact that the Choose Wisely campaign is a intended to be a campaign to promote discussion between providers and patients about the appropriateness of certain interventions across the spectrum of health care. But the language that emerged from the American Chiropractic Association is not about that discussion, it is a definitive statement “do not x-ray”, not “be cautious”, not “be mindful” not “restrain yourself”, it is “do not” and the pushback that has come from certain circles in the United States, is about the definitive nature of that comment in relation to the intent of the process. If the language were modified to reflect “be careful”, “be cautious”, “be restrained” etc. and give professional latitude to even a minimal degree to the practitioner you might find a radically different response in the United States.”
Dr. Maiers: “It is an excellent point and the American Chiropractic Association has gone through another iterative process of engaging a very broad sampling of the chiropractic community across the United States, including our DACBR community, including some people who were completely against the way this was phrased and what we have worked out is a revision of the language.”
At the WFC/ECU Congress no less than three plenary speakers, Gregory Kawchuk, D.C., Ph.D., Jan Hartvigsen, D.C., Ph.D. and Pierre Cote, D.C., Ph.D. aggressively and unprofessionally attacked Life University’s position of non-support of the Choosing Wisely elements related to spinal imaging promulgated by the American Chiropractic Association.
The irony of the matter is that the ACA representative on the same program admitted that language of the statements Life University chose not to support was under revision by the ACA.
If it needs revision, it was inappropriate in some way and the reservations of Life University are justified.
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Gerry Clum, D.C.

Director, The Octagon
Life University
Gerry Clum, D.C.

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