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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 25-July-2008, Vol 121 No 1278

Doctor Who? Inappropriate use of titles by some alternative “medicine” practitioners
David Colquhoun
Who should use the title ‘doctor’? The title is widely abused as shown by Gilbey1 in this issue of the NZMJ in an article entitled Use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy. Meanwhile, Evans and colleagues,2 also in this issue, discuss usage and attitudes to alternative treatments.
Gilbey finds that the abuse of the title doctor is widespread and that chiropractors are the main culprits. An amazing 82% of 146 chiropractics used the title Doctor, and most of them used the title to imply falsely that they were registered medical practitioners. Although it is illegal in New Zealand to do that, it seems clear that the law is not being enforced and it is widely flouted.
This is perhaps not surprising given the history of chiropractic. It has had a strong element of ruthless salesmanship since it was started in Davenport, Iowa by DD Palmer (1845–1913). His son, BJ Palmer, said that their chiropractic school was founded on “...a business, not a professional basis. We manufacture chiropractors. We teach them the idea and then we show them how to sell it” (Shapiro 2008).
It is the same now. You can buy advice on how to build “build high-volume, subluxation-based, cash-driven, lifetime family wellness practices” http://www.teamwlp.com/about-wlp/index.html
In her recent book, Rose Shapiro comments on the founder of chiropractic as follows:
...By the 1890s Palmer had established a magnetic healing practice in Davenport, Iowa, and was styling himself ‘doctor’. Not everyone was convinced, as a piece about him in an 1894 edition of the local paper, the Davenport Leader, shows...
A crank on magnetism has a crazy notion hat he can cure the sick and crippled with his magnetic hands. His victims are the weak-minded, ignorant and superstitious, those foolish people who have been sick for years and have become tired of the regular physician and want health by the short-cut method...he has certainly profited by the ignorance of his victims...His increase in business shows what can be done in Davenport, even by a quack
DD Palmer was a curious mixture: grocer, spiritual healer, magnetic therapist, fairground huckster, religious cult leader—and above all, a salesman. He finally found a way to get rich by removing entirely imaginary ’subluxations’. Over 100 years later, it seems that the “weak-minded, ignorant, and superstitious” include the UK’s Department of Health, who have given chiropractics a similar status to the General Medical Council.
The intellectual standards of a 19th Century Mid-Western provincial newspaper leader writer are rather better than the intellectual standards of the UK’s Department of Health, and of several university vice-chancellors in 2007.

Do the treatments work?

Neither Gilbey nor Evans et al really grasp the nettle of judging efficacy. The first thing one wants to know about any treatment—alternative or otherwise—is whether it works. Until that is decided, all talk of qualifications, regulation, and so on is just vacuous bureaucratese. No policy can be framed sensibly until the question of efficacy has been addressed honestly.
It is one good effect of the upsurge of interest in alternative treatments that there are now quite a lot of good trials of the most popular forms of treatments (as well as many more bad trials). Some good summaries of the results are now available too.
Cochrane reviews set the standard for good assessment of evidence. New Zealand’s Ministry of Health commissioned the Complementary and Alternative Medicine website to assess the evidence, and that seems to have done a good job too. Their assessment of chiropractic treatment of low back pain is as follows:
There appears to be some evidence from one systematic review and four other studies, although not conclusive, that chiropractic treatment is as effective as other therapies but this may be due to chance. There is very little evidence that chiropractic is more effective than other therapies.
And two excellent summaries have been published as books this year, both by people who have had direct experience of alternative treatments, but who have no financial interest in the outcome of their assessment of evidence. The book by Singh and Ernst3 summarises the evidence on all the major alternative treatments, and the book by Bausell4 concentrates particularly on acupuncture, because the author was for 5 years involved in research in that area,
Both of these books come to much the same conclusion about chiropractic. It is now really very well-established that chiropractic is (at best) no more effective than conventional treatment. But it has the disadvantage of being surrounded by gobbledygook about “subluxations” and, more importantly, it kills the occasional patient. Long (2004)6 said “the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45.
The chiropractors of Alberta (Canada) and the Alberta Government are now facing a class-action lawsuit.7 The lead plaintiff is Sandra Nette. Formerly she was a fit 41 year old. Now she is tetraplegic. Immediately after neck manipulation by a chiropractor she had a massive stroke as a result of a torn vertebral artery.
Acupuncture comes out of the assessments equally badly. Bausell (2007) concludes that it is no more than a theatrical placebo.

Are the qualifications even real?

It is a curious aspect of the alternative medicine industry that they often are keen to reject conventional science, yet they long for academic respectability. One aspect of this is claiming academic titles on the flimsiest of grounds. You can still be held to have misled the public into thinking you are a medical practitioner, even if you have a real doctorate. But often pays to look into where the qualifications come from.
A celebrated case in the UK concerned the ‘lifestyle nutritionist’, TV celebrity and multi-millionaire, Dr Gillian McKeith, PhD. A reader of Ben Goldacre’s excellent blog (http://www.badscience.net) did a little investigation. The results appeared in Goldacre’s Bad Science column in the Guardian.8
She claimed that her PhD came from the American College of Nutrition, but it turned out to come from a correspondence course from a non-accredited US ‘college’. McKeith also boasted of having “professional membership” of the American Association of Nutritional Consultants, for which she provided proof of her degree and three professional references.
The value of this qualification can be judged by the fact that at Goldacre sent an application and $60 and as a result “My dead cat Hettie is also a "certified professional member" of the AANC. I have the certificate hanging in my loo”.

Is the solution government regulation?

In New Zealand the law about misleading the public into believing you are a medical practitioner already exists. The immediate problem would be solved if that law were taken seriously, but it seems that it is not.
It is common in both the UK and in New Zealand to suggest that some sort of official government regulation is the answer. That solution is proposed in this issue of NZMJ by Evans et al. A similar thing has been proposed recently in the UK by a committee headed by Michael Pittilo, vice-chancellor of Robert Gordon’s University, Aberdeen.
I have written about the latter under the heading A very bad report (http://dcscience.net/?p=235). The Pittilo report recommends both government regulation and more degrees in alternative medicine. Given that we now know that most alternative medicine doesn’t work, the idea of giving degrees in such subjects must be quite ludicrous to any thinking person.
The magazine Nature5 recently investigated the 16 UK universities who run such degrees. In the UK, first-year students at the University of Westminster are taught that “amethysts emit high yin energy” http://dcscience.net/?p=227. Their vice chancellor, Professor Geoffrey Petts, describes himself a s a geomorphologist, but he cannot be tempted to express an opinion about the curative power of amethysts.
There has been a tendency to a form of grade inflation in universities—higher degrees for less work gets bums on seats. For most of us, getting a doctorate involves at least 3 years of hard experimental research in a university. But in the USA and Canada you can get a ‘doctor of chiropractic’ degree and most chiropractic (mis)education is not even in a university but in separate colleges.
Florida State University famously turned down a large donation to start a chiropractic school because they saw, quite rightly, that to do so would damage their intellectual reputation (http://dcscience.net/?p=231#fsu). This map, now widely distributed on the Internet, was produced by one of their chemistry professors, and it did the trick.
Other universities have been less principled. The New Zealand College of Chiropractic [President “Dr Brian Kelly”, B. App Sci (chiro)] (http://www.nzchiro.co.nz) is accredited by the New Zealand Qualifications Authority (NZQA). Presumably they, like their UK equivalent (the QAA), are not allowed to take into account whether what is being taught is nonsense or not. Nonsense courses are accredited by experts in nonsense. That is why much accreditation is not worth the paper it’s written on.
Of course the public needs some protection from dangerous or fraudulent practices, but that can be done better (and more cheaply) by simply enforcing existing legislation on unfair trade practices, and on false advertising. Recent changes in the law on unfair trading in the UK have made it easier to take legal action against people who make health claims that cannot be justified by evidence, and that seems the best way to regulate medical charlatans.

Conclusion

For most forms of alternative medicine—including chiropractic and acupuncture—the evidence is now in. There is now better reason than ever before to believe that they are mostly elaborate placebos and, at best, no better than conventional treatments. It is about time that universities and governments recognised the evidence and stopped talking about regulation and accreditation.
Indeed, “falsely claiming that a product is able to cure illnesses, dysfunction, or malformations” is illegal in Europe.9
Making unjustified health claims is a particularly cruel form of unfair trading practice. It calls for prosecutions, not accreditation.
Competing interests: None.
Author information: David Colquhoun, Research Fellow, Dept of Pharmacology, University College London, United Kingdom (http://www.ucl.ac.uk/Pharmacology/dc.html)
Correspondence: Professor D Colquhoun, Dept of Pharmacology, University College London, Gower Street, London WC1E 6BT, United Kingdom. Fax: +44 (0)20 76797298; email: d.colquhoun@ucl.ac.uk
References:
  1. Gilbey A. Use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy. N Z Med J. 2008;121(1278). http://www.nzma.org.nz/journal/121-1278/3160
  2. Evans A, Duncan B, McHugh P, et al. Inpatients’ use, understanding, and attitudes towards traditional, complementary and alternative therapies at a provincial New Zealand hospital. N Z Med J. 2008;121(1278). http://www.nzma.org.nz/journal/121-1278/3159
  3. Singh S, Ernst E. Trick or Treatment. Bantam Press; 2008 (reviewed at http://dcscience.net/?p=239)
  4. Bausell RB. Snake Oil Science. The Truth about Complementary and Alternative Medicine. Oxford University Press; 2007
  5. Colquhoun D. Science degrees without the Science, Nature 2007;446:373–4. See also http://dcscience.net/?p=19
  6. Long PH. Stroke and spinal manipulation; 2004. http://skepticreport.com/sr/?p=88
  7. Libin K. Chiropractors called to court. Canada: National Post; June 21, 2008. http://www.nationalpost.com/story.html?id=602815
  8. Goldacre B. A menace to science. London: Guardian; February 12, 2007/ http://www.guardian.co.uk/media/2007/feb/12/advertising.food
  9. Department for Business Enterprise & Regulatory Reform (BERR). Consumer Protection from Unfair Trading Regulations 2008. UK: Office of Fair Trading. http://www.oft.gov.uk/shared_oft/business_leaflets/530162/oft931int.pdf
This paper was corrected on 11 September 2009 as per the Erratum at http://www.nzmj.com/journal/122-1302/3783
     
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