Peeve Post #1: Chiropractic X-ray Abuse
From time to time on this blog I’ll rant about pet peeves. My goal is to provoke healthy debate and discussion, and hopefully provide some impetus to long-needed change, and ultimately help patients receive a higher standard of care. Every profession has its warts; chiropractic is no exception.
In this post I tackle the ugly truth about the use of x-ray images to sell multiple-visit care packages to prospective patients. This is not what radiology is supposed to be for, yet this shameful marketing practice continues in 2015.
Getting Our Bearings
In their book Selling Sickness Ray Moynihan and Alan Cassells level a powerful indictment against the pharmaceutical industry, and the broader health care industry, for attempting to “medicalize” everything. They note that PMS has become a psychiatric disorder, hyperactive children all have ADHD and need a prescription, and most of us are “at risk” because the “safe range” for blood cholesterol levels have been so low we all qualify for a daily dose of statin drugs. And the advent of the MRI, a very sensitive imaging technique, shows so much abnormality that 3 or 4 items of diagnostic concern will be identified in over half of those imaged who have no symptoms whatsoever.
Is it against this fair and balanced backdrop that, most certainly to the chagrin of many chiropractors overusing x-rays, I lament Chiropractic X-ray Abuse.
Selling Sickness Chiropractic Style
The problem is not that chiropractors can order, perform, interpret or report on diagnostic radiographic images. I am proud of the education I received in school covering radiation physics, x-ray technique, and diagnostic x-ray interpretation while in chiropractic college. Further, neither time or space would allow me to innumerate the good that has been brought about from chiropractors who use diagnostic radiology judiciously and who have served their patients honorably, even saving lives. This post is not about the privilege of use. In fact, the chiropractic profession was born in 1895, the same year Wilhem Roentgen discovered x-rays in Bavaria, and chiropractic was among the first health care professions to incorporate “roentgenology” into clinical practice.
The problem is the use of x-rays by chiropractors to “Sell Sickness,” much like those who’s job it is to expand their profit margins by selling stuff in the medical arena. In the case of statins, for example, it is not the medical physician who sells the drug; the pharmaceutical company does this for her. How many drug commercials in America (or New Zealand, where commercials are also legal) end with: “Ask your doctor if _____ is right for you.”
How Chiropractic X-ray Abuse is Done
In some chiropractic clinics the decision to take x-rays is a foregone conclusion. It is so routine, in fact, that you might not even see the chiropractor until after a member of the clinic staff x-rays you. This is usually a postural x-ray that is obtained with you sitting or standing upright and erect with opposing frontal and lateral views. In some cases you might also be x-rayed while bending or rotating your body.
In cases where you do see the chiropractor first, it’s the same drill. You are going to get x-rays, period. The reason? The x-ray films will be placed on a view box or computer screen and marked with black (or better yet, red!) crayon (or its digital equivalent) with one and only one purpose: to prove to you that you are damaged and need repair.
To summarize, postural distortions that will be found on you x-rays and the superimposed lines are intended to scare you; to “sell” the fact that you are “sick.”
To this day many chiropractors will tell you that you have a pinched nerve, and that your vertebrae (the bones in your spine) are “out of place.” I hear this on the radio here in Denver: “If the nerve to your ______ (liver, thyroid, etc.) is pinched, it is just a matter of time before you’ll get ______ (liver, thyroid, etc.) cancer.” Thankfully this type of chirobabble is on the decline, but it’s out there. Doesn’t it seem that some of the worst elements in any given profession are the ones who are the most vocal and visible. Embarrassing. Deplorable. Weightless. Greedy. Or if sincere, sincerely wrong!
The Treatment Plan
The x-ray presentation is just the first part of your “report of findings.” You’ll be asked to bring your spouse back on a subsequent visit to discuss how broken, damaged and fragile you are, and to scare both of you some more. Then you’ll talk finances.
Some chiropractic marketing gurus teach that if the chiropractor can get new prospects to come back 3 or 4 times in short succession for a structured indoctrination (again, called the “report of findings”) they can close the sale on your life-long dependence on chiropractic care. The financing is linked to the number of visits that will be needed to correct your problem (usually dozens; among the braggadocious — 100 or more). Prepayment with a credit card always wins a discount. Always best to zip the plastic before one begins. If not, “financing is available.”
Note the Negative Consequences
First, you’re told you need x-rays. Ionizing radiation is not inconsequential. The benefits in any given situation must outweigh the risks. Using x-rays to sell a multiple-visit chiropractic plan of care is not a good reason to send ionizing radiation through people.
Second, you’re made a victim. Not the victim of criminal activity. You’ve been made the helpless, passive recipient of bad news about which you can do nothing. You have a “subluxation” and you need the chiropractor to fix it for you. And that is going to take a long time and lots of “corrections.” Weeks. Months. Or perhaps years. OMG.
Third, the idea that you are “fragile” has been reinforced. The “hand on the stovetop burner” episode from youth is a great lesson in pain. Our earliest education in the school of pain tells us that “pain means tissue damage.” Right? This belief carries over to our views toward back pain, neck pain, headaches and other common ailments seen by chiropractors. The x-ray reinforces that there is something damaged in there, and that you are fragile. You need to learn to depend on the skills of the chiropractor to help you because you are not able to help yourself. “Your low back is not stable, Mrs. Smith.” Translation: “You are fragile, broken and helpless.” It doesn’t help that the pain you are feeling is so severe that this tends to validate the chiro-story you are being told.
Fortunate or not, back pain, neck pain, and headaches are usually not signs of tissue damage or fragility. Some pain experts (e.g., Kieran O’Sullivan, Ireland) equate back pain with stomach ache. It happens as part of life experience, but it doesn’t mean your stomach is (necessarily) broken. Pain researchers (e.g., David Butler, Lorimer Moseley) teach us that feeding our fears, equating pain with tissue damage, and increasing our self sense of fragility all add up to only one sorry thing: more pain. Chronic pain.
Add the 3 items above together and what you get is a totally botched opportunity (not YOUR fault!) to get over the pain and get on with your life, free and independent of endless, ongoing passive spinal adjustments/corrections.
It Goes On!
What is unbelievable to me is this: it is 2015 and this type of thing still happens with some frequency. Happily, consumers of healthcare are getting savvy. Crap-detectors are on an all-time high; people are vigilant about hucksterism. But the take-home message is worth heeding: If you are standing in front of an x-ray view box hearing how messed up your spine is — maybe it is! But if, subsequently, you’re asked to zip your credit card for thousands and being assured it is a good deal, turn and run.
For those of you looking for ammo against the chiropractic profession, get a life. Start by looking in the mirror at your own profession. It’s fraught with problems too. Maybe I’ll post a pet peeve about it someday. In the meantime, calling attention to chiropractors who are behaving badly by no means diminishes the fact that their are the vast majority of my colleagues who do good. I hope they are willing to read this far into the post and hear and feel what I am saying. We are a clinical science. Many, if not most of us, are educated, passionate, and evidence-based. But clearly I am calling the bad apples to the carpet, here.
Some people with neck pain, back pain or headaches have a serious condition. X-rays may be entirely appropriate in the initial diagnostic workup of your problem, especially if it is severe, wakes you up and night, won’t go away, is associated with fever or night sweats, or is associated with loss of appetite, weight loss or weight gain. This blog is for informational purposes only. It is not intended to diagnose, treat, cure or prevent any disease or illness. Neither do the comments made in this blog constitute medical or chiropractic advice. if you have a question about your health, including whether you do need an x-ray examination or not, please see your chiropractor, medical physician or other health care practitioner to “ask if x-rays are right for you.” 🙂
Thanks for reading!