Selling sickness weighs the virtue of maintenance care in the practice.
More than a third of a century ago, Mr Henry Gadsden, chief executive of Merck, told the renowned magazine, Fortune, that he wanted his drug company to be more like the chewing gum manufacturer, Wrigley.
What did he mean? Continuing, Gadsden said it had long been his dream to make drugs for healthy people, because then Merck would be able to sell to everyone.
This is the starting point and central thesis of Moynihan and Cassel's new book; that pharmaceutical companies are working to turn us all into patients, and in the process generate ever bigger profits for themselves and ever greater costs for health care systems.
They make a compelling case that big drug companies have intentionally used their influence to broaden the definition of disease to expand their markets.
For example, they report that Glaxo Smith Kline has claimed that seasonal affective disorder, also known by the acronym SAD, disturbs 1 in 8 Americans. Other definitions put the prevalence variously at less than one percent or, in some studies, up to four. By more broadly defining the criteria, the pharmaceutical company created a greatly expanded market for its drug, Paxil, the first medication approved for the treatment of the condition associated with the long winter deprivation of light.
The United States has less than 5 percent of the world’s population but half of the global market in prescription drugs.
I enjoy reading research. There are so many unanswered questions in health, not least in chiropractic, and I greatly admire those who make the time to delve into the mysteries of Mark Twain’s lies, damned lies, and statistics. The least we can do is read their conclusions, a healthy dose of scepticism not withstanding as we question whether this is just another case of using dubious figures to bolster a weak case. Sometimes, perhaps, we should also be a little sceptical of our own scepticism!
Thomas Honee, a colleague from a local Limburg town, posted us the results of a questionnaire that he sent to 100 medical doctors asking their opinions about various things. Criticism number one; chiropractors make their patients dependent on them, demanding they return again and again on a regular basis.
That was fair comment. Is it valid? Can it be justified? I too encourage the majority of my patients to return every two or three months for a check up. Was I making them psychologically and physically dependent on me? Was it prevention rather than trying to make a cure? Am I no better than Henry Gadsden?
Was the reason the betterment of their health, or to pay for the Fat Boy that I had been admiring in the local show room? That new bike does not come cheap. In fact it costs roughly treble the price of our small car. Holland is definitely Harley-Davidson country, and they regularly spoil my cycling trips as they thunder past in their classic black helmets, leaving me with my tongue hanging out in their dust and fumes; ah, jealousy.
Worry nagged at my conscience for the next few weeks until I realized the only way to resolve the issue was to analyse my practice. Out came pen and paper and then a move to make a spreadsheet, with a little help from Helen.
The result of the analysis was interesting, but it was the last day of the survey that really confirmed the yearning gulf that lay between chiropractic and medical care. When there is something to be learnt, it all seems to happen in one disturbing moment.
iGood morning, Mijnheer Snepvangers. How have the last few months
gone, I asked, using the still challenging Dutch grammar? He had been a moderately famous professional football player
thirty years ago, a defender for the local Red pro team, before family
and business commitments demanded that he return to the amateur game.
Very good, doctor. I walked fifteen kilometres with my family on Sunday with no pain in my hip until the last half an hour. It was a bit stiff the next day, but now it is fine again.
He called me doctor, which I appreciated, even though chiropractors are not recognized as such in the Netherlands. Medics, and much of the public I regret, consider us krakers, or lay manipulators.
We think the appellate applies only to health professionals who have attended a few weekend courses on manipulation. Enough said. Can you learn to bake a decent loaf of bread after a course lasting a few days?
I asked Mr Snepvangers to walk up and down; he had a slight limp. After I examined his back where there was that nagging fixation in the right sacroiliac joint and again checked the ranges of motion of his hip. It was indeed no small miracle. Even the movement we call adduction, that was so severely limited at the first consultation, now over a year ago, was remarkably good and, more important, largely pain free. Stiff, and certainly not normal, but the man could walk fifteen kilometres. I went back to his dossier. A report to your doctor is long overdue, Mr Snepvangers. Let me see, in the beginning you said you couldn’t walk more than half an hour before you had to stop, is that right?
Mr Snepvangers nodded. Ten years ago, our whole family used to go for a long wandel every Sunday, unless the weather was inclement. But the last few years. He threw up hands, and expression of disgust twisting his otherwise handsome features. Dutch men are handsomer than their wives beautiful, I think. I like that word; it adds something more to simply going for a walk.
We might take the train to Groningen for the day. Or Zeeland, always somewhere different, he continued. Leave early on a Sunday morning, walk until we were exhausted, stop at a little cafe for lunch and a beer, and hike for another three hours, before going home.
Groningen? Where is that?
It is the northernmost province of the Netherlands. I think it is the most beautiful.
I made a mental note to add it to our list of places to visit, though Helen and I would prefer to take the bicycles with us on the train, and ride through Holland’s quaint old villages.
And now, what are you doing?
Like I said, last Sunday we went to the Achterhoek, and had a wonderful day. Not as far as I used to walk it is true, but it was altogether marvellous being back with the family.
I added it, too, to my bucket list; the back corner.
They started going without you?
He nodded. After six months, I insisted. My wife and the kids got so moody weekends sitting around at home. But then I started putting on weight, and I would often drink half a dozen beers while they were away, and my doctor even had to put me on some anti-depressants. That is all gone now.
And the pills, you were taking anti-inflammatories every day when you first consulted me, I said, glancing at my notes.
He nodded. That is why I came in the beginning, you remember. My stool went black, and my doctor said I should stop the pills.
Just in time. Thousands of people die every year from a stomach bleed caused by anti inflammatories. It is one of the known side effects.
‘I wish he had warned me when he first prescribed them!’ he added, indignantly.‘Research has shown it’s especially dangerous when prescribed together with anti-depressants. ‘And do you still take them?’
He grinned. ‘Sometimes. Not the anti-depressents, but I did swallow a Cataflam on Monday after the wandel. ‘Just watch the toilet, and if you start to get pain in the tum …’He nodded.
‘Give me a ball park figure. How much better would you say you are in comparison with a year ago? 30%, 90%?’ I always give a wide extreme so they can choose fairly.
He scratched his head thinking. ‘The pain in my hip is at least 75 percent better, but my lifestyle has improved by ten times that amount,’ he said with a smile. ‘Plus your treatment saved me the operation on my knee that the orthopaedic surgeon was recommending.’
I nodded. I can well understand the average GP not appreciating the subtleties of an arthritic hip, but I was indeed astonished that the surgeon had not realized that the pain in Mr Snepvangers’s knee was simply a very typical referral from the hip.
‘I do not need to ask you if you are doing the daily hip exercises, but are you also taking the salmon and cod-liver oil and chondroitin sulphate?’ He grimaced, and nodded.I put his x-rays up on the screen, just to remind myself of a few details. I shook my head, still astonished that he was so much better. The typical arthritic signs were all in an advanced state: the loss of joint space, the heavy layer of calcium laid down in the roof of the hip joint, and the advanced changes in the head of the femur, with cysts of fluid in the ball.
I examined his hip again noting the typical ‘capsular pattern’ as we call the arthritic hip. The greatest improvement had been in what we call adduction: the movement of the knee towards the opposite side. The very movement I was least expecting to improve. ‘One last question, Mr Snepvangers. How important do you think this two monthly consultation is?’
‘Absolutely vital. Within six or seven weeks it is beginning to stiffen up again and my back starts aching when I make that long drive to our factory in Friesland. Mind you, I miss having my wife on the trip. She has gone back to her old job.’ Mr Snepvangers makes a long three-hour drive to their factory in the north every two weeks. The pain in his back and hip had got so bad that his wife had to quit her job and start chauffeuring him. I put a tick in the column, headlined: Maintenance: vital, and got on with the treatment.
The next few hours were routine, with ten patients in various stages of care for resolving acute conditions. Mostly they were progressing well, though there was one man I wasn’t happy with. He had his own business and refused to take off time for a nasty sciatica. Long hours of sitting was hindering progress with weakness developing in his ankle. The column headed: Acute, resolving received nine ticks.
Acute, progressing got one. I insisted he take a roll-up mattress to work, and lie down for ten minutes every hour and do the exercises I had prescribed.The eleventh patient was altogether another matter. She was angry. ‘Good morning, Mrs Zuidema. I wasn’t expecting you for another three months. What’s happened?’
‘I have been so sore since the treatment last week. What did you do to me?’
‘I’m sorry about that, mevrouw. Think back, tell me what happened?’
‘I went straight home after the treatment on Monday evening, made supper for the family, but within an hour I could hardly stand. I was careful like you told me to be, nothing stupid.’ She added, very annoyed and I was nonplussed.
‘You didn’t sneeze or anything? Did you take a short walk around the car park after the treatment like I instructed you to do? ’She glowered. ‘Of course.’
I examined her and there was no doubt that her condition was not good. There was no pain in her leg like there had been at her first consultation nearly nine months ago, but forward bending was quite limited and painful again, as were several orthopaedic tests. I went back to my notes. She had been in for three of these two-monthly "maintenance" treatments, and we had agreed to space it out to three months. It was the only the third that had caused a problem. We call it iatrogenic, or doctor-caused disease, and I was certainly guilty as charged. For some reason I had adjusted her spine first, and her sacro-iliac joint afterwards, just the opposite to the last nine treatments. Could that be the reason?
The column: Maintenance. Result: acute exacerbation fortunately received only one tick that day.
The next patient was an elderly lady, with an acute low back condition. She struggled to get out of the chair and I could see she was jammed in a forward flexed position. Any attempt to straighten and extend her back immediately provoked a sharp pain down her leg. ‘You are going to need some help at home for the next days, Mrs Hulscher. No housework, and please try and sit as little as possible. Can your husband bring you for the treatment? I don’t want you to drive.’
She eyed me and her lower lip quivered for just a moment. ‘My husband is dead.’
I cursed myself, glancing at the file again. How did I miss her ‘widow’ status, so clearly filled in? ‘I’m sorry,’ was all I could manage, aware that I had ridden roughshod over her feelings. Actually it opened a much-needed crack in the door. I suppose, living all alone, she had been bursting to tell someone. Anybody, even the chiropractor. They had no children and she, sadly, had had only one friend and now he was dead: ‘He went in for a routine hip operation four years ago and never came home. He was only sixty-five,’ she sniffed.
I knew that night I would again be churning over an old hobby-horse. When is it better to accept the limitations of an arthritic hip, or even a life-threatening aneurism? Or should one go for major surgery that might relieve the problem, but the attendant risks of the anaesthesia or a fatty embolus were reasonably high. I wanted to ask if he was a smoker, which so greatly increased the risks of surgery, but didn’t dare add more misery to her already miserable life. There was no merit in adding guilt to loneliness. Her clothes reeked of smoke, but fortunately her back responded quite quickly but not without some irritation to us both.
‘Mr Preston, the chiropractor who used to attend to me before you came, gave me a much harder adjustment than that. I always heard a cracking sound in my back. Will it get better with such a gentle adjustment?’
I like the Dutch. They are a forthright nation of people who are ready to speak their minds. Sometimes it comes over as hurtful and abrupt, but I find in the end it is much better for all parties when we speak the truth to each other, even if it’s uncomfortable. ‘All chiropractors are different, Mrs Hulscher. He did it his way, I do it mine. In any case you now have quite advanced osteoporosis and giving you a hard manipulation would not be wise.’
She nodded, but I could see she was unconvinced. I wondered if I would see her consulting one of my more-robust colleagues. One of the rules in our clinic is that the patients are absolutely free to choose their chiropractor of choice. It’s a good rule. But the next day, as Mrs Hulscher stood up from the waiting room chair to shake my hand, I could see it was chalk and cheese. ‘Minor’s sign’, that warning sign that we look for whenever we greet the sitting patient, was absent: She stood up from the chair without using her hands to walk up her legs, her smile confirming what I already knew. Body language is important is the work of the astute doctor.
‘It’s much better, doctor,’ she said. I noted with amusement the change from ‘mister’ to ‘doctor’: respect is something we have to earn. It doesn’t necessarily come with the degree. ‘But how is it so much better without the crack. I don’t understand, I thought it was that cracking sound that made all the difference.’
‘I find there is often no audible cracking sound at the first treatment, Mrs Hulscher, perhaps because of the spasm, but some movement is induced into the joint. Then, at the second or third treatment, it usually will give you an audible release. In actual fact, there is some research that reports that it makes absolutely no difference to the outcome whether you get a cracking sound or not.’ Fortunately Mrs Hulscher was rewarded that day with a sharp, audible ‘release’, and within two or three weeks her condition had stabilised. ‘You must of course go on with the exercises. It hasn’t healed yet. Please be extra careful for the next two or three weeks.’ Acute. Not on maintenance care.
Midway through the afternoon I had another routine patient who unfortunately also got a tick in the Chronic: Unresponsive column. ‘How is your hip doing, Mr Kreukniet?’ I asked. He was a delightful elderly man also with advanced arthritis in the hip. We had grown quite fond of each other in the four weeks he had been coming in for a trial period before a hip operation.‘Doctor, I have decided to go for the operation. I’ve had the eight treatments that my insurance allows for Chiropractic and I’m afraid I just can’t afford your fees. There has been a slight improvement but I have just talked to my doctor and he insists that I must have the operation.’
I inwardly cursed Holland’s medical insurance industry that would happily shell out tens of thousands for advanced medical care without giving conservative care a fair chance. I also cursed their taxman, who made it obligatory for us to add 21% VAT to our bills making it inordinately expensive to consult a chiropractor. No such taxes were added to the fees of medical doctors, physiotherapists or even medical manipulators. The doctor who was bullying my patient also got a few curses. His patient too, I reminded myself. ‘But Mr Kreukniet I told you that you could not bank on significant improvement in the first two months and you haven’t lost any of the weight that I recommended.’ He was at least thirty kilos over weight.‘I know but it’s hopeless. I just can’t lose it, and I can’t afford you. I’m sorry.’
I nodded wondering whether to play my ace. I decided against it, knowing that he had already weighed these things. At the first consultation he had shared with me their great distress when his twin brother went in two years ago for a hip replacement. (The opposite side, they were two mirror images. He showed me a photograph.) Brother Jan died in surgery.
As it turned out Mr Kreukniet’s surgery was wonderfully successful, but only after the wise surgeon, and his bullying GP, insisted he first lose fifteen kilograms. Mr Kreukniet and I had become just a little too friendly which prevented me from putting in the sharp blade and giving it a hefty twist. A good hip operation can be a wonder.
My very last patient of the day as it turned out, the second new patient, also had a hip-knee condition. It had been a long day, and I forced myself to concentrate. He had been a runner until the last six months, jogging about 40 – 70 kilometres a week.‘Explain please, Mr Koekkoek, where is this pain in your hip? Here in the ball joint, in the buttock, or here in the sacro-iliac joint?’ I patted the prominent bump on the right side of his low back. ‘Does it radiate into your groin or down the leg?’
‘It is here on the side of my hip and my butt. It does sometimes radiate into the groin and, yes, it does run down to my knee.
’Was it a sciatica, was it a hip, was it something more complex? There were dozens of possibilities. ‘And your doctor says it is a bursitis?’ He nodded. I went on with the rest of the history and then asked him to undress for the examination. It took less than sixty seconds to establish that it was indeed another advanced arthritic hip. I was one thousand percent sure; the capsular arthritic pattern, especially when advanced, is so easy to detect. When you know what to look for, that is.
‘How can you be so certain? My doctor says it is in this bursa!’
‘Because I have been in the business of joints for thirty years, Mr Koekkoek, and I have examined and treated thousands of arthritic hips. That bursa is no more tender than the other side, and it’s not the slightest swollen.
Sometimes in the early stages it may be quite difficult to detect an arthritic hip but yours is so typical that I will lay my reputation on a block. You have what we call Cox arthritis, and it’s quite advanced.’He thought for a moment. ‘Years ago I had pain in the other hip.’ He pointed to his right side. My doctor sent me to an orthopaedic specialist who said it was early arthritis and, yes, that it was in both hips. He told me I would be back in ten years. It’s ten years!’
‘Did he give you any suggestions about caring for your hips? Reducing your running and changing to cycling or swimming, some specific exercises, any supplements?’ I raised my eyebrow.
He shook his ahead. I sighed. It had been a long day, and there was absolutely nothing I could do about changing the way so many medical doctors were against prevention and maintenance when it came to joint conditions. Or were ignorant that so much could be done. Insurance companies too received a heafty dose of my spleen.
That willingness to pay out huge sums for surgery, that is at least some of the time needless, makes absolutely no sense to me, particularly since there is so much research now confirming that inclusion of chiropractic saves them significant dollars. We went off the x-ray room and within ten minutes my diagnosis was confirmed.
‘Can you help me, doctor? What sort of guarantee can you give me that your treatment for this arthritis will help?’
‘None I am afraid. But I can give you a reasonable assurance that it will help, and if it does not I will be honest enough to tell you. But please first commit yourself to at least two months treatment before we make the final decision. Otherwise there is no point in starting. There will not be any miracles.’ Fortunately, being a successful businessman, he could afford the treatment out of his own pocket.
The final tally for the day: 38 patients.
Acute, resolving: 25
Acute, progressing: 1
Chronic, maintenance vital: 8
Chronic, unresponsive: 1
Chronic, maintenance, acute exacerbation: 1
New patients: 2.
It had been a long day, and I was exhausted. It was a beautiful spring evening, just light enough to ride home without the dynamo acting like an anchor. March wasn’t waving her tail, as she is want to do in Holland, and I decided to make the half hour ride, rather than take the bus, knowing that I would arrive sweaty but refreshed, ready for a hot shower and a game of scrabble with she who must be obeyed. This is Holland after all, and ‘thuis, vrouw is baas’. At home, Helen is without a doubt the boss!
‘What’s the matter, Bernie?’ Helen emerged after supper from the shower, with just a towel wrapped around her, steam rising from her still pink skin. Normally I would immediately lose all interest in the book or report that I was working on, but after one glance at her, I returned to my deliberations on the day’s tally. She walked over to where I was engrossed at the computer.‘I hurt a lady quite badly this week with a bit of carelessness. I’m trying to decide whether these maintenance treatments are really justified.’
‘I’m not really sure. I changed the usual protocol I had being using to treat her. Not sure why. Too much of a hurry I suppose. Anyway she came in happy as lark with chiropractic and left very disgruntled. I hope she gets better again.’
‘How often does it happen?’
‘Not very, but perhaps too often. Perhaps I should go back to my old philosophy of, if it’s not broken, don’t fix it.’‘What are the benefits?’ She put her arm on my shoulder, concerned. It’s not often I get down, even slightly depressed.‘For me, I will soon be able to buy that Harley!’
‘Oh, go on! You know what I mean. What are the benefits for the patient?’
‘I don’t know of any research proving anything, but we think it helps prevent relapses, and keeps the joints mobile. What has been proved with white mice …
‘Poor white mice,’ she interjected.
‘… we do know that the histological signs of cartilage degeneration begin within thirteen hours of spinal fixations being induced. But then you get these acute exacerbations from the maintenance care every now and again.’
‘Does medicine get these ‘exacerbations’ as you call them?’
‘I guess. We call it iatrogenic disease. Doctor-caused disease.’
‘Didn’t you once tell me that it’s the third most common disease? How do you rate?’
‘Not as bad as that.’
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