Last summer BCA president Tony Metcalfe tried to calm members concerns about Simon Singh by telling them“How many of your patients are aware of what is going on”

April 19, 2010
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This guy has been president of the World federation of Chiropractic and this comment will always make me laugh. To be honest I did not think the case would be as big as it became, but the BCA people must have been on a different planet.

In the June BCA members Newsletter “In Touch” the President of the BCA Tony Metcalfe reassures members and advises them to keep the Simon Singh issue “in perspective”. He asks “how many of your patients are aware of what is going on? I can tell you that none of my patients have raised any issues of concern with me and are not in the slightest bit interested in the Singh legal action” I was reminded of Basil telling the staff, “dont mention the war to the Germans.

As bad as this is for the chiropractic profession one can only laugh at the naivety or stupidity of the BCA leadership, they are complicit in allowing the profession to be judged on practices that account for less than five percent of what chiropractors see in practise. Ben Goldacres article (below)suggest this controversy  may only be beginning. Its like one of those “Revenge of the Nerds” movies.

The leadership of the UK chiropractic profession do little hoping this will just go away. The reality is the controversy is gathering momentum internationally. Its had wide spread coverage in Austrialia, last Sunday the Irish Independent picked it up, at yourownriskAmericans will love the BCA suing  Simon Singh because he called chiropractic bogus.

Will Trick or treatment hurt the chiropractic profession the way the Ralph Lee Smith book did in the the 60s. As Eleanor Roosevelt said “Only if you let them”. First though Tony Metcalfe et al must go, before the rehabilitation can begin.

An intrepid, ragged band of bloggers by Ben Goldacre The Guardian

Chiropractors may regret choosing to sue Simon Singh, springing online scientists into action

Today the Australian magazine Cosmos, along with a vast number of other blogs and publications, reprinted an article by Simon Singh, in slightly tweaked form, in an act of solidarity. The British Chiropractic Association has been suing Singh personally for the past 15 months, over a piece in the Guardian where he criticised the BCA for claiming that its members could treat children for colic, ear infections, asthma, prolonged crying, and sleeping and feeding conditions by manipulating their spines.

The BCA maintains that the efficacy of these treatments is well documented. Singh said that claims were made without sufficient evidence, described the treatments as "bogus", and criticised the BCA for "happily promoting" them. At a preliminary hearing in May, to decide the meaning of this article, Mr Justice Eady ruled that Singh’s wording implied the BCA was being deliberately dishonest. Singh has repeatedly been clear that he never intended this meaning, but has been forced to defend this single utterance, out of his own pocket, at a cost that has run to six figures.

Soon we will get to the story of the backlash, but first, while you may view this as a free speech issue, there are also some specific worries raised when people sue in medicine and science.

It is possible in healthcare to do great harm, while intending to do good, and so medicine thrives on criticism: this is how ideas improve, and therefore how lives are saved. The three most highly rated articles in the latest chart from the British Medical Journal are all highly critical of medical practice. Academic conferences are often bloodbaths. To stand in the way of ideas and practices being improved through critical appraisal is not just dangerous, it is disrespectful to patients, and even if someone has been technically defamatory in their wording, it is plainly undesirable for all critical discourse in healthcare to be conducted in a stifling climate of fear. Neither the General Medical Council nor the British Medical Association have ever sued anyone for saying that their members are up to no good. I asked them. The idea is laughable.

But beyond whether it is right, there is the more entertaining issue of whether it was wise, and here it is hard to contain a sense of schadenfreude as the chiropractors’ world unravels. First, there is the media exposure. This case and the chilling effects of libel threats in science have now been covered by the Times, the Daily Mail, the Daily Telegraph, the Independent, Nature, the Economist, Times Higher Education, the Sunday Times, Channel 4, the Financial Times, the Wall Street Journal, Private Eye, the Observer, the BBC, and an editorial in the British Medical Journal, to name just a few. This story has travelled around the world.

Most of these articles drew attention to the evidence for chiropractic’s efficacy, which is often not compelling. Some discussed chiropractic’s dubious origins: it was invented by a magnet therapist, convicted of practising medicine without a licence, who suddenly decided in 1895 that 95% of all diseases are caused by displaced vertebrae, and compared himself to Christ, Muhammad and Martin Luther. Who knew?

An international petition against the BCA has been signed by professors, journalists, celebrities and more, with Ricky Gervais and Stephen Fry alongside the previous head of the Medical Research Council and the last government chief scientific adviser. There have been public meetings, with stickers and badges. But it is a ragged band of science bloggers who has done the most detailed work. Fifteen months after the case began, the BCA finally released the academic evidence it was using to support specific claims. Within 24 hours this was taken apart meticulously by bloggers, referencing primary research papers, and looking in every corner.

Professor David Colquhoun of UCL pointed out, on infant colic, that the BCA cited weak evidence in its favour, while ignoring strong evidence contradicting its claims. He posted the evidence and explained it. LayScience flagged up the BCA selectively quoting a Cochrane review. Every stone was turned by Quackometer, APGaylard, Gimpyblog, EvidenceMatters, Dr Petra Boynton, MinistryofTruth, Holfordwatch, legal blogger Jack of Kent, and many more. At every turn they have taken the opportunity to explain a different principle of evidence based medicine – the sin of cherry-picking results, the ways a clinical trial can be unfair by design – to an engaged lay audience, with clarity as well as swagger.

Then the formal complaints began. There have been successes with the Advertising Standards Authority, including one which concluded that claims to treat colic breached the guidelines on "truthfulness" and "substantiation". This interested many, since treating colic was a claim sued over by the BCA when Singh called it "bogus".

Professional complaints followed in May, mostly about individual chiropractors’ claims. Then, in June, blogger Simon Perry found the BCA database of 1,029 members online, containing 400 website URLs. He wrote a quick computer program to automatically identify all the chiropractors in the UK claiming to treat colic, locate their local Trading Standards office, and report them (more than 500 in total) automatically, followed up with printed letters.

Chiropractic is also a profession regulated by the General Chiropractic Council, supervised by the Health Professional Council, which are obliged to investigate all complaints. So Perry reported over 500 chiropractors to them, alleging they had made claims without adequate evidence. The GCC rejected his letter, saying it only takes individual complaints. A pile of individual complaint letters were instantly generated and delivered to their door. Astonishingly, ZenosBlog had done exactly the same thing. These 1,000 complaints are now being investigated.

You may view this as bullying individuals, and initially I had some sympathies. But my heart was hardened, reading commentary from the chiropractic and alternative therapy community, saying Singh must expect six-figure consequences for criticising them, and transgressing the letter of the law, even in just one article.

Some clue to whether chiropractors feel able to defend these complaints over the evidence for their practices came a few days later. On 8 June the McTimoney Chiropractic Association sent a confidential email to its members, which has been obtained and is available in full on Quackometer. "If you have a website," this email begins, "take it down NOW … REMOVE all the blue MCA patient information leaflets, or any patient information leaflets of your own that state you treat whiplash, colic or other childhood problems in your clinic … IF YOU DO NOT FOLLOW THIS ADVICE, YOU MAY BE AT RISK FROM PROSECUTION. Finally, we strongly suggest you do NOT discuss this with others" – and on this they were clear – "especially patients."

The MCA says this is a "vexatious campaign against the profession", that it has nothing to hide, and believes its members have not intentionally breached any rules regarding their websites’ content. The entire MCA website disappeared on the same day, and continues to be nothing more than a holding page (it "is currently being updated"), but its former site, along with every single chiropractor’s website, has been archived in full online by the science blogging community, for anyone who is interested to look.

We could go on, but there are lessons from this debacle – beyond the ethical concerns over suing in the field of science and medicine – and they are clear. First, if you have reputation and superficial plausibility more than evidence to support your activities, then it may be wise to keep under the radar, rather than start expensive fights. But more interestingly than that, a ragged band of bloggers from all walks of life has, to my mind, done a better job of subjecting an entire industry’s claims to meaningful, public, scientific scrutiny than the media, the industry itself, and even its own regulator. It’s strange this task has fallen to them, but I’m glad someone is doing it, and they do it very, very well indeed.

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Related posts:

  1. Richard Brown Vice President of British Chiropractic Association argues that the criticism of his profession is wide of the mark
  2. Journalist explains how the BCA has damaged the chiropractic profession, by going after Simon Singh
  3. If Simon Singh is not allowed to express his opinions in the UK, chiropractic is finished, in fact it would never have started.
  4. BCA donkeys just keep digging.
  5. The BCA’s decision to sue Simon Singh will be a disaster for the profession
  6. Last June Jack of Kent summarised the BCA’s decision to sue Simon Singh.
  7. BCA and GCC member David Byfield would seem to concur with Simon Singh that the BCA were making bogus claims about the efficacy of chiropractic
  8. More people supporting Simon Singh
  9. Tuesdays Telegraph article about Simon Singh case.
  10. The British Chiropractic Association have perfected the art of putting heads in sand.

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  • http://spinaljoint.com Richard Lanigan

    Hi Gutherie,
    Most of the sceptics who come here are genuinely sceptical and engage in reasoned discussion. I have experienced the dogma of many of the so called skeptic sites they are not sceptical at all and want orthodox order in ther world.

    As for the complaints, I can not see Zeno giving up 700 days to be cross examined on each of his complaints. Only worry if the BCA cut a deal with the GCC to accept an admonishment for most of the members to avoid further embarrassment for the GCC and BCA alliance.

    I can not understand why the BCA policy does not cover these complaints, I stayed with MIA when I left the BCA and they cover all forms regulatory hearings. I suspect BCA members will be railroaded into this, just as they went after Simon Singh without consultation.

  • Guthrie Steer

    Hi Richard

    I’ve no idea where the smart chiros are..! The bloodbath of the more vociferous anti-chiro skeptic sites certainly puts me off contributing there. It gets way too personal & there’s pretty much no chance of a reasoned conversation.

    Also having already had a complaint made against me by ‘Zeno’ I have been reluctant to stick my neck out & potentially ask for more.

    I’m not worried about all that by this stage & the tone here is pretty calm & reasonable at the minute so I’m happy to chip in – long may it continue..!

  • http://spinaljoint.com Richard Lanigan

    Gutherie, you made a much better stab at answering Benji than I did, When are all the smart chiropractors going to lift their head above the parapet. I tended to doze off in methodology lectures and like Richard Brown I am not the best person to talk about evidence.

  • Guthrie Steer

    Hi Richard – Great to see you’ve got the blog back up & running – very nice.

    Hi Benji – I would challenge your assertion that RCT is the only way to establish causality. I agree that establishing sub-groups with an identifiable patho-anatomy is the holy grail for lots of orthopaedic injuries but in the absence of those sub-groups an RCT is as likely to disregard an effective treatment as it is to endorse one.

    It seems to me that to varying degrees, the ‘Skeptic Brigade’ (to continue the division into neat camps) do have a devotion to the exclusive use of RCT’s. A lot of the more ardent ‘no RCT = no evidence’ supporters also appear unfamiliar with the practical realities of clinical decision making & find it attractive because RCT’s are so clear cut. Unfortunately, individuals with presenting complaints are rarely, if ever, clear cut.

    Many clinical presentations fall under a homogeneous title but have heterogeneous causality. So for example, an RCT into a lower back pain group gives absolutely no information on causality because the correlation between presenting symptoms of lower back pain and the precise patho-anatomy is not clearly understood. That is a significant limitation to the value of exclusive application of RCT’s in any manual therapy.

    So, after all that, it appears to me that the ‘Skeptic Brigade’ don’t seem to appreciate the difficulty and importance in establishing causality..!

    I also think it is unrealistic to think that small scale observational, and individual case studies will inform further research if treatment protocols are being imposed externally by statisticians. That’s not sense about science – that’s sense about statistics & may have the ‘chilling effect’ of creating manual therapy of all flavours applying clumsy stat based recipes to highly variable individuals – all of which is unlikely to improve treatment quality or patient outcomes.

  • http://spinaljoint.com Richard Lanigan

    I did a posting on this somewhere I will republish it.
    A lot of the high profile sceptics seem to limit research to RCTs. There are sceptics like yourself who have done a science degree and recognise the difficulty in establishing causality in something like chiropractic which requires a high level of skill for the intervention to work. Prescribing a drug only requires knowledge of the evidence for its use.
    In the 80s statisticians who focused merely on outcomes, decided the best way to score a goal was to ignore the skill level involved and lump the ball into the box. This was called the position of maximum opportunity ( POMO)and was very damaging to English football. The ignored all the variables involved in the build up which could not be controlled. They decided the goal was caused by the position the ball was in before it was put in the net. Scientists say a baseball player does not react fast enough to hit a fast ball, yet he can do it because he has the skill, however not everyone has and not all chiropractors have the skill and why many use ultrasound and interferential and noe the want to prescribe.

  • Benji

    Hi Richard,

    I don’t think all skeptics workship RCTs as much as you make out. An RCT is the only way to establish causality, which is a very difficult thing to find.

    Other aspects of evidence, such as case studies, small scale ovservational studies etc can inform an interesting area of research in order to establish if what has been seen in the small scale trials is due to the intervention or not.

    I think, (or I would hope!) that many skeptics realise this. The CAM brigade don’t seem to appreciate the difficulty and importance in establishing causality.

    Regards

    Benji

  • http://spinaljoint.com Richard Lanigan

    Hi noodles,

    For some reason Skeptics seem to think I can not bee a bona fida sceptic because I practice CAM, with the exception of one or two the sceptics who come on to this site, they are pleasant people who are happy to engage and we can agree to disagree at the end of a discussion. Scepticism with orthodox medicine is why I gravitated towards chiropractic. To be fair Simon Sing is very chilled and I like the man, Andy Lewis at Quackometer on the other hand can not accept he might be wrong about anything to do with CAM. I will republish those postings over the next few days. They make interesting reading.
    I have been on sceptic sites where you make a comment and they turn into a rabbit mob because you practice CAM. There was one where I did not get the difference between Plummer as in someone’s name and a plumber. I am dyslexic and could not see the capital P and with my spelling they assumed I must have had no education, I kept replying because I was curious how obnoxious they could be.
    Funny thing about Skepics with a K, they remind me of the story when Moses came down the mountain with the Ten Commandments and his followers were adoring “false images ” . The story goes this contraveined the first commandment and Moses lost it and smashed the commandments.
    Skeptics have a very limited understanding of Sackets model of evidence based practice. They believe; RCT is the lord thy God! and thou shall have no other Gods but him. Heaven help anyone who tries to introduce empirical evidence or qulaitive research into the discussion. Most health care practitioners build their practices on the false God, Empirical. Chiropractic, medicine are arts they are not exact sciences.

  • Paul

    Noodles

    Whilst this summation may not include you I think it is within fair comment to state that the vast majority of skepdicks are discourteous, self righteous, ill informed, ego masturbators with little or no understanding of anatomy, physiology, health, or the wider constructs within research or practice, and with little or no intention past self satisfaction and adulation within the adolescent like peer group that contains them.

  • http://spinaljoint.com Richard Lanigan

    Hi Michael Kingsford Gray, you are right but if you look at how its been presented now its as if everything chiropractors do is “bogus” and they were deliberately misleading the public as simon Singh says there is no biological reason why spinal manipulation should help otis media or colic. This is simply not correct, the evidence is not strong but the anatomical connections are there.

    Hi Dix-Hallpike I dont believe you are in the minority but few chiropractors have taken the time to explaine the professions position in recent months and that has been very damaging. The BCA took a unilateral decision to sue Simon with a disregard for the rest of the profession, just as they are seeking prescribing rights for its members. They have now withdrawn from this debacle and will stand back while sceptics dump on the entire profession from a height

  • Dix-Hallpike

    So, now we all come up for air. After all this scrapping I realise that nothing’s really changed in my life. Yes, I scanned my web site for any real shockers and luckily I found that I had, unintentionally, not followed the GCC advice but stuck to what I do best and nothing needed to change. My patients who are far from ignorant or vulnerable still like what I do, I still care for them to the best of my ability (yes, Noodlemaz, some of us do this because that’s just how we’re built and you are being unfair, prejudiced and untruthful to suggest otherwise), they refer their friends to me because they trust me and I get good results.

    I will never apologise for chiropractic because it works. I’ll always be disappointed with the sKeptics for bullying us all once they found that they had some clout but they should be ashamed as there were far, far better things they could have done with their amazing amounts of time and energy. Additionally, I am also glad that the whole debacle has tightened up the research that supports what I do.

    And I can’t believe that I am in an extreme minority in this.

  • Michael Kingsford Gray

    I good article, considering.
    But I feel that you tended to portray Simon’s opposition in this case by the BCA far too broadly, in several places in the article.
    Simon’s ‘bogus’ claims apply specifically to his listed conditions: Infant colic, etc.
    You, of all people, know exactly of what his list consists.

    I feel that you owe it to Chiropractors to make this abundantly clear. A naive reader could get the impression that Simon has labelled every bit of chiropractic as ‘bogus’.
    This is clearly not true.

  • http://spinaljoint.com Richard Lanigan

    Hi Noodlemaz,
    First I wrote this last summer and am republishing them because its always worth looking back to see the mistakes that were made.

    Why should I stay under the radar when I have no doubt spinal care helps childrens health. My evidence is called empirical and it comes from clinical experience. The irony of this case is the people who brought this case would have very little experience treating children and are probably as sceptical as you are about its efficacy.

    As for people lying or being dishonest. That is hardly exclusive to the chiropractic profession. Like any profession we have our share of snake oil salesman. When you talk of chiropractors “fleecing people that are genuinely ill” I presume you are not talking about children with colic. In which case I would argue that the chiropractic profession is far from top of the league on that score and way behind medicine and the church.

    AS for “giving a shit about people” I dont think the bloggers can claim a monopoly of that. If you really care about people, I have a list of things you could help me with that are far more important than whether chiropractic helps colic. The survivors of abuse in catholic schools. The Cuban Five. Ending the US blockade of Cuba. People who wont clear the snow of their footpaths. Making regulatory bodies accountable. Inequality in health and education. child labour. Use you energies to help people , because one day someone will show you how spinal joint dysfunction can irritate nerves and affect the autonomic nervous system and you will realise that it was prejudice that motivated you rather than wisdom and you were not helping anybody by believing all chiropractors are charlatans.

  • http://noodlemaz.wordpress.com Noodlemaz

    Very nice article, thank you for writing this.
    Though I have one issue with it, as it seems people are still missing the point here:

    ‘if you have reputation and superficial plausibility more than evidence to support your activities, then it may be wise to keep under the radar, rather than start expensive fights.’

    Maybe it’s wise to stop using people’s ignorance and vulnerability to make money from them. Maybe it’s wise not to lie (knowingly or otherwise) about what your business is. Maybe it is wise to turn ‘superficial plausibility’ into evidence, if indeed it can be found – and if it can’t, do something else.

    Perhaps I should replace ‘wise’ with ‘ethical’ or ‘decent’ or ‘somewhat less evil’.

    ‘Oh my god we might end up losing expensive fights’ shouldn’t be a reason for people to stop fleecing patients, people who are genuinely ill and looking for some hope and spending their hard-earned cash to get it.

    The reason the ‘ragged band of bloggers’ has come together isn’t because we have nothing better to do – it’s because we give a shit about people, and that’s what we want to see in businesses dealing with human beings. It’s probably too much to ask, but we can dream, right?

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