ROBERT D. MOOTZ, DC   First response

This section is compiled by Frank M. Painter, D.C.
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This article does have bias, but its not an anti-chiropractic one.

Two assumptions in the study reflect an excessive pro-science bias:

1.  Appropriateness criteria based on existing literature and derived by a multidisciplinary panel made up of a majority of researchers are adequate for practitioners to base care decisions on;

2.  Convenience chronology categories such as acute, sub- acute, and chronic used in research studies are an accurate and adequate way of categorizing patients in clinical practice. An editorial by Godlee on the applicability research findings to clinical practice and the LPB follow-up on patients presenting to family docs (both in BMJ in the past several weeks) reflect the disparity of opinion within medicine on these two kinds of issues. Its too bad the authors didn't devote more discussion to these issues and I hope someone writes a letter to the editor about it.

To the author's credit, the title of the article and their discussions of limitations of the study methodology accurately portray the what the study did find out. They should be acknowledged for truthfully conveying what their data (with its obvious constraints) does show:  When stacked up against medical practice using appropriateness criteria (with all of that methods inherent limitations), we perform similarly. They did not (understandably) do a comparison to the second RAND appropriateness panel made up of all chiropractors, which would have probably raised the "score" a few points. What particularly struck me and offered encouragement was that the "random" record reviews of chiropractic charts were able to extract adequate data to pursue the study. That means to some extent, we are keeping better records in general practice than I feared we were.

The ramifications of this study reflect something very important: Scientists, non-DC providers, and other opinion leaders are taking what we do seriously. Albeit small "n" anecdote, the folks in my agency workgroup (a neurologist, 2 internists, and an attorney) commented about how chiropractic has really come of age by funding this kind of critical research of themselves (and I thought no one read acknowledgments! Their thoughts on the results? "Yup, DCs are human just like the rest of us"). The implications for quality improvement, self-reflection, willingness to objectively examine the clinical decisions we make will permit us greater access to seats at the decision making tables of the future. John Triano pointed out in another e-mail exchange that this article also provides ammunition to confront our adversaries on the double-standard for evidence often required of us.

This is a very useful and beneficial study for us. In my opinion, perhaps of even greater benefit to us socially than the RCTs that show we have a slight edge in satisfaction or functional outcome when being compared to less-than-state-of-the-art medical practices. Think about it folks, when ordinary, everyday Joe and Jane Chiropractors' records are stacked up against criteria derived from the toughest, most evidence-biased scientists and clinicians by the most rigorous and evidence-biased think tank in the world, we are found out to be as responsible and reasoned in our patient selection as our medical colleagues. Rather than reflecting bias, it strongly reinforces how unsupported anti-chiropractic bias is. Powerful stuff indeed.

I really like Triano's observation: "The glass ceiling hasn't fallen, but its getting more porous."


Robert D. Mootz, DC
Associate Medical Director
State of Washington Department of Labor and Industries

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