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Back Surgeons, Chiropractic, and the Murder of a Federal Agency on Evidence-Based Medicine PDF Print E-mail
Written by John Weeks   

Back Surgeons, Chiropractic, and the Murder of a Federal Agency on Evidence-Based Medicine


"In 1993, the federal government's Agency for Health Care Policy and Research convened a panel to develop guidelines for back surgery. Fearing that the recommendations would cast doubt on what doctors were doing, a prominent back surgeon protested ... and lawmakers slashed funding to the agency."

                                        -- Business Week, May 29, 2006

The note above recounts the cold-blooded murder of a federal agency. The agency was charged with bringing order to medicine. The strategy was to develop guidelines which would help make medicine evidence-based. When the evidence challenged significant medical powers, the agency was offed.

This history has been largely hidden, for a decade. It deserves a telling of more than a paragraph, and more than what I can give it here.

 
This history has
been largely hidden
for a decade. It
deserves a telling,
like the stories of
those who disappeared
under Latin American
distatorships. It
deserves more
clarity and detail
than I can give it.

I heard of the
murder of the AHCPR
first, for sure,
in 1996 ...


I first heard, for sure, of this killing in 1996. I heard it directly from a high-level official of the Agency for Health Care Policy and Research (AHCPR). He told me it was so, at point blank range, beside a swimming pool in Tucson, Arizona, after a one-day conference co-hosted by the AHCPR at which I presented. I said: "Is it true that AHCPR was killed because of the back pain guideline?" The AHCPR had issued a guideline that recommended that acute low back pain is best addressed through watchful waiting and manipulation. He answered, simply: "Yes." Then he followed quickly: "And if it's ever sourced back to me, I will deny having said it." I haven't written it since.

I was shocked, honestly - still am - to see
medicine's power so ruthlessly displayed. The hit is harder yet, given the polarization around evidence in the emergence of the CAM fields back then, and still today. The typical telling places CAM in a netherworld of not caring about scientific evidence (never mind the lack of funding, back then especially). Conventional medicine, meantime, in this telling, is all swaddled in the evidence flag.

Now, 
10 years later, the powerful details of the May 27, 2006 Business Week article shows us the economic base - not evidence-base -  of U.S. medical decision making. We can appreciate the forces in the environment which allowed the rest of conventional medicine to sit by and watch an upset surgeon murder the AHCPR.  (See the Business Week detail in an earlier IBN&R article.)

This was medical terrorism of the first order. Take the deified "evidence pyramid" with reviews of randomized controlled trials at the top. Frost it with a multi-stakeholder, multi-year exploration of all the evidence available. Develop a guideline. Now bomb it. Why wasn't the
American Medical Association and academic medicine on hand to rebel against it?

The story of the AHCPR's demise should be a part of any practitioner's education about evidence and medicine. The story particularly should be part of the education of any CAM-IM advocate who has been told that their soft medicine is outside the tough love EBM standard of those on the inside of medicine's power circles.
Yes, there is the evidence. And then there is the politics of evidence.

The AHCPR's body needs to be exhumed and put on display.

Here is a brief recounting of a personal tale about the AHCPR, and of a CAM-IM integrator's relationship with that doomed agency. It is not, unfortunately, the investigative account this story deserves. Rather, this is a personal story of a way that agency created a possibility, the killing that followed, and now this aftermath in which we live.

A Parable of
the Wild West of US Medicine, and a Federal Marshall ...

Imagine U.S. medicine as a wild-wild west, where the firm justice of scientific evidence has not yet arrived. In the place of the rule of evidence, we have power set by families - let's just call them tertiary care medical specialties, shall we? - who run the town. They go about doing what they want. They say it is all for the good.

But there enters a force that would like to see a more civilized, egalitarian, less prejudiced approach. They propose a Rule of Evidence. They convene experts to review the situation. They come up with a new law, codified in sets of evidence-based guidelines.

Now the US Marshall, guidelines in hand, rides into town. He announces that doing whatever you want, because you can, won't any longer be the law of the land. He rides in, white hatted, promising a new order.

He is shot in the heart, and dies. The White Hat is murdered.
It was not like this on 1950s television when the good guys always won ...

And those who were pushing the Rule of Evidence via the federal agency got the message: Try pushing for federal guidelines again, the same end may come to you. 


AHCPR and it's Power to Tame Medicine's Excesses

In the early 1990s, I served for a time doing some national affairs work for a new player on the national scene, the American Association of Naturopathic Physicians. The association represented graduates of federally-recognized colleges. My job was to find ways the profession might begin to play a role in the federal policy discussion.

In this capacity, I learned of the work of the AHCPR. This agency was charged by Congress
 
The AHCPR was
to
be an ongoing
partner, for years
to come,
in efforts
toward betterment
of
US medicine.


with being a federal arbiter of evidence and a setter of guidelines. This Congressional empowerment of the AHCPR was part of the growing national movement to begin managing care through linking practitioner choices to scientific evidence.

The AHCPR's process was to be simple, deliberate, and unfolding over time. One by one, the AHCPR was to choose conditions, focusing on high-cost, high-use conditions first. An early focus was on low back pain. Among the others empowered was a panel to examine evidence regarding treatment of headaches. To create buy-in, the AHCPR would convene multi-disciplinary panels of 18-25 experts. Highly-regarded researchers would chair the panels. The products would serve three audiences:

  • for researchers, a small book which included the recommended guideline and all the evidence on which it was based;
  • for practitioners, a 12-page booklet with key evidence highlighted; and
  • for citizens-patients, a brochure which would lay out the clinical recommendations in plain language.

The guidelines would be updated, as new evidence was produced. The AHCPR would be an ongoing partner in the betterment of US medicine.

Glasnost: The Dream of the AHCPR in the Emerging Integration Dialogue

The AHCPR effort intrigued me.

While neither practitioner nor researcher, my work in natural health care since 1983 had surrounded me with CAM and holistic medical professionals who had become experts in surveying the research literature. They began publishing the evidence that much of mainstream care hadn't the evidence it projected.
I'd worked with a CAM school, now Bastyr University, which was dedicated to "science-based natural medicine." My colleagues Joseph Pizzorno, ND, and Michael Murray, ND, had published in 1985 a seminal volume, A Textbook of Natural Medicine. The book was another fruit of this scouring of the world literature made possible by the growing accessibility of computers. The volume suggested that the evidence for natural medical and healing approaches was not getting the respect it deserved.

Perhaps a naturopathic physician might be put up for an appointment to an appropriate panel.
I noted that among the two dozen experts selected for the panel on low back pain there was at least a token chiropractor. Was this a place where we could see the truth outed, let the chips fall where they may? Tokenism would be a start.

 
The AHCPR effort
and the low back
guideline felt like
medical glasnost,
tearing down the
walls between the
disciplines, a whole 
new world opening. 


I left the job in mid-1993, and never had a chance to see the political work through. But as a journalist, in a column for the Townsend Letter for Doctors, entitled Charting the Mainstream, I continued to follow the AHCPR's work. I wrote up an article on the guideline for low back pain when it came out. Here was the startling finding: amidst all of the pharmaceuticals and other interventions in the conventional, multi-billion dollar low-back pain industry, the AHCPR guideline was clear. The evidence was for watchful waiting or manipulation. The latter was mainly practiced by a single discipline, chiropractic.

The guideline arrived in 1994, just five years after the chiropractic profession won a 10 year anti-trust suit against the AMA, forcing an end to egregious defamation of chiropractic, and others, by medicine's powerful guild. Would the new campaign for evidence-based medicine help to further drive prejudice from medical decision-making? Would the AHCPR guidelines prove an ally in the integration process?

The AHCPR effort and the low back guideline felt like medical glasnost, the tearing down of the wall, a whole new world opening.

The
Death of the AHCPR

For the Clinton healthcare reform effort, the idea of EBM was marched out to define the revolution which "managed competition" promised. EBM's founder, David Eddy, MD, PhD, and the Jackson Hole Group with which he was associated, became nearly household names.  In fact, much of the ugly dearth of evidence paraded before the public by Business Week last month made its debut on the national stage in 1992-1993 to support the Clinton's effort to find a way to managing medicine.

The reform effort failed, for many reasons. Doctors chafed at being mana
ged.
They complained of violation of the doctor-patient relationship. They didn't like being told that

Mission
accomplished:


By 1996, there
was no significant
evidence-based
medicine guideline
effort left at the
federal level.


evidence suggests that what they were doing was not okay. That maybe the evidence didn't support it. Or that what the doctor was doing was even damaging and sometimes killing people. Always, evidence meant the doctor's practice needed more reflection.

Back care, a major money maker in the orthopedic wings of hospitals, showed a particularly questionable pattern. Often worthless. Often harmful. The most variable. The evidence that most influenced the level of treatment appeared to be demographic data on the number of surgeons who were around and needed feeding. Frequently expensive. Full of adverse effects. And here was Big Brother, the AHCPR, marching into the room with a little booklet says: Watchful waiting and, worse yet, manipulation. And the devils themselves: Chiropractors!

By 1996, when I had my conversation with the high-level AHCPR official by the Tucson pool, the AHCPR was a shell. The entire guidelines effort had been disbanded. The effort to publish and distribute completed guidelines terminated. There was no significant EBM guideline effort left at the federal level.

In 2002, I managed a telephone conference with a group of experienced researchers who were
to be on a panel at the 2002 Integrative Medicine Industry Leadership Summit. I was urging them to publicly explore the politics of evidence. I suggested that the story of the killing of AHCPR be at the center. Two of teh panelists-to-be held, or had held, significant positions in the NIH. They all knew the AHCPR story. They shared with me the blunt lesson the agency's killing gave those inside the beltway and in the broader research and practice community. The whole subject of developing federally-backed guidelines as an agent to transform medicine became a non-starter. If you wanted a project funded, don't make it about guidelines.

The public, for better and worse, eventually bought the case of the poor, put-upon physician, struggling against the faceless bureaucracy of the hated HMO. Often for good reason. Yet here we are, in 2006. The very same David Eddy is the featured personality in the Business Week expose. The cry is still for EBM. And our medicine is hardly more evidence-based than it was when the EBM "revolution" began.

Lessons and Reflections


It might be a
good thing
to
find the
surgeon
and
bring him up
on charges.

He'd be in some
ugly company in
global history,
responsible for
a parade of dead
stretching on
into the millions
by now.


My interest in revisiting the killing of the AHCPR is akin to something going on politically in Chile and Argentina today. Both current presidents were dissidents in the 1970s when dictatorships began to systematically "disappear" thousands of opponents. The presidents, despite calls to let the ugly past be forgotten, have both found it important to re-open the old wounds. They believe it important to seek justice.

I am not sure where the justice is here. In the Business Week telling, one "prominent back surgeon protested, and lawmakers slashed funding to the agency." Others have told me it was a neurosurgeon. Others have put the finger on one, prominent, Texas back group. I have had a medical colleague from Texas tell me that the whole story about the surgeon is bull. I don't know.

That said, it might be a good thing to find the surgeon and put him up on charges. We'd need to produce the list of all who have been killed and maimed through the system's subsequent failure to produce, promote and practice with evidence-based guidelines. To estimate a number: Just last week, Donald Berwick, MD, MPH, founder of the Institute for Health Improvement, claimed that 122,300 were saved last year alone when many of the nation's hospitals finally began following evidence on a half-dozen procedures.(1) Our powerful surgeon would be in some ugly company in global history, responsible for a parade of dead stretching on into foreever if we are to sum up a decade of these dead, alone.

But to focus on the one, or the small group, is to approach this like the Warren Commission approached the Kennedy murder, determined to prove it was a single killer. The Great Bad Man Theory takes us away from the more significant fact.


Does anyone believe
a single surgeon
could kill the AHCPR
  if the AMA had raised 
a hand in protest?


Does anyone believe that a single surgeon could have killed the AHCPR if the AMA had raised a hand and begun a campaign in protest? I expect, at the very least, a massive, passive sigh of relief was breathed by untold tens of thousands of doctors and the scores of organizations that lobby for them. Just a toast of good riddance.

Those Bad Chiropractors

I can honestly say that at least a two dozen times I have been forced to raise the chiropractic question when I have interviewed my medical doctor colleagues about their efforts to integrate CAM into the offerings of their hospitals and academic health centers.

When I ask about provider mix, they tick off the massage therapist, the acupuncturist, the nurse Reiki specialist, the mind-body practitioner, the Yoga teacher. I wait for the "C" word. Chiropractors typically aren't in the mix. (See Integrative Clinics - An Analysis of 27 Clinics for some evidence.) My most recent such encounter was within the last two weeks. I remind them all of the AHCPR guideline, of evidence that, at worst, is mixed.

Question:  Why aren't you including chiropractors? Heck, all you have to do is find one you trust and tell your medical staff that look, here, the chiropractor will be under my supervision ...

Answer:  If I did that, the orthopedic docs would kill this before it got off the ground. I want to get it going, first, with providers who aren't as controversial.  Chiropractors will come later. Phase 2.

The spirit of that supposedly lone, powerful surgeon, amidst all the talk of EBM, still reaches deep into the medical landscape.
Funny how, in a classic example of mirror-imaging - seeing in the other what your refuse to acknowledge in yourself - chiropractors are portrayed by conventional medicine as adversarial, always filing lawsuits, not good collaborators. If there is clear justice in this tale of the murder of the AHCPR, it is that chiropractic has earned a right, for better or worse, to be adversarial.

A lesson for all interested in integration is that quality evidence, if necessary, is for certain not sufficient. Witness the work of John Astin, PhD. funded by 
NIH NCCAM, to begin to understand why mind-body medicine, given its evidence base, is not better integrated into care delivery. Our strategies should reflect this unfortunate evidence. My colleague Lou Sportelli, DC, long ago shared with me the two words which he says have been most responsible for his profession's advances: legislation and litigation.

 
Now the idea
of the Rule of
Evidence is often
appropriated by
one or more of
medicine's powerful
economic clans
to lash
those
less
well-heeled.
 
What is the federal legislation we need to really move this field?

Meantime, we are clearly making advances, step-by-step, row-by-row, human-to-human, educator-to-educator, clinician-to-clinician, discipline-to-discipline - and even based on evidence.

Yet the murder of the AHCPR should remind us that we are still living in the wild, wild West of medicine. It's just that now the idea of the Rule of Evidence is often appropriated by one or more of medicine's powerful families to lash those less well-heeled and to keep things rolling as they always did, in the good old days.


(1) "Hospitals bid to heal selves saves thousands." Seattle Post-Intelligencer, Thursday, June 15, 2006. Page 1.

Your comments (this links to an IBN&R forum on this topic)

 


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