- Email: [email protected]
MANIPULATING THE PATIENT A COMPARISON OF THE EFFECTIVENESS OF PHYSICIAN AND CHIROPRACTOR CARE
1333 —a historical
legacy of the Greek humoral theory and the Hippocratic-Galenic tradition.8 Problems associated with the organisation and delivery of health care in rural Iran. These problems relate to the vacuum in rural health care, particularly the paucity of physicians for referral or supervision. Problems associated with village social structure.
B.
C.
The difficulties with rival factions are in this Also, personality characteristics of the category. v.H.w. (such as the desire to move up from village to city, and concern with status, particularly the accoutrements of the physician, such as white coat, stethoscope, and hypodermic syringes) are important factors influencing his or her effectiveness. CONCLUSION
On the basis of our limited experience in Iran, believe that the Chinese barefoot doctor is not easily transplantable to Iranian soil, and that auxiliary
we
Occasional
Survey
MANIPULATING THE PATIENT A COMPARISON OF THE EFFECTIVENESS OF PHYSICIAN AND CHIROPRACTOR CARE
ROBERT L. KANE CRAIG LEYMASTER DONNA OLSEN F. ROSS WOOLLEY F. DAVID FISHER Department of Family and Community Medicine, University of Utah College of Medicine, Salt Lake City, Utah 84132
Patients identified through Workmen’s Compensation records as having been treated for back or spinal problems by a chiropractor (122) or a physician (110) were interviewed to determine their functional status before and after the accident and their satisfaction with the care received. In terms of both the patients’ perception of improvement in functional status and patient satisfaction, the chiropractors appear to have been as effective with the patients they treated as were the physicians. The two groups of patients were not significantly different with regard to age, sex, race, education, marital status, income, hypochondria, or attitudes about the medical profession in general.
Sum ary
INTRODUCTION
THE medical
profession’s disdain for chiropractic has existed since the first emergence of the practice at the end of the nineteenth century. None the less, the public turns to chiropractors for assistance in ever more substantial numbers. Kuby cites two studies from the mid-1950s which suggest that 5-7% of the families surveyed had consulted a chiropractor during the previous year. Over 16% of the respondents expressed a willingness to use such a practitioned 1 Despite the opposition of organised medicine, chiropractors are now eligible for reimbursement under Medicare as a result of PL 92-603. Ballantine represents the position of many physicians 2: "The inclusion of chiropractic in any health care
in Iran must take into of the rural situation. There is
training
<
account a
great dt
REFERENCES 1. 2.
3. 4. 5. 6. 7.
8.
Sidel, V. W. New Engl. J. Med. 1972, 286, 1292. Sidel, V. W. Int. J. Hlth Serv. 1972, 2, 385. Ronaghy, H. A., Cahill, K., Baker, T. D. J. Am. med. Ass. 1974, 227, 538. Ronaghy, H. A., Solter, S. L. Lancet, 1973, ii, 427. Gringras, G., Geekie, D. A. Can. med. Ass. J. 1973, 109, 150A. Horn, J. Away With All Pests. New York, 1972. Pickowicz, P. G. in Modern China and Traditional Chinese Medicine (edited by G. B. Ruse); p. 124. Springfield, Illinois, 1973. Livingston, R. B., Mahloudji, M. Pah. med. J. 1970, 3, 38 (abstr.)
program, public or private, is not in the public interest. There is no reason to believe that further studies of chiropractic would bring forth new facts to negate the findings previously published by knowledgeable investigators of
unquestionable integrity."
Ironically, there is a scarcity of scientific data the validity of chiropractic theory or the effectiveness of chiropractic therapy. The first experimental study of the basis for the theory of vertebral manipulation to be published in a recognised scientific journal appeared in 1973.3 However, the public continues to find solace in the services offered by these practitioners, as evidenced by the continued use of their services. In recognition of this public support and prompted by the current medical furore over the Medicare regulations, we felt it appropriate to attempt an evaluation of the effectiveness of chiropractic treatment, regardless of the theoretical validity of the methods. If chiropractors are able to improve their patients’ functional levels, as judged by the patients on
themselves, this evidence would be
a
first step in
bringing factual data and rational discussion overheated subject.
to
an
METHODS
To establish our sample, we reviewed all claims of the Utah State Insurance Fund (Workmen’s Compensation) between July and December, 1972, to identify neck and back injuries (table I). From these, those patients living within an hour’s travelling time from the university were listed. Workmen’s Compensation permits the injured worker to select his therapist from among physicians, TABLE I-UTAH STATE INSURANCE FUND WORKMEN’S COMPENSATION NECK AND BACK INJURIES, JULY-DECEMBER, 1972 —————————————————————.———————————,————————————————
*
145
randomly sampled for this study.
t Included in study.
1334
osteopaths, and chiropractors. For the study period and geographical area specified, records were identified for 147 chiropractor (D.C.) patients and 336 medical (M.D.) patients; 13 patients had used osteopaths and 44 had consulted both a physician and a chiropractor. For 67 cases the type of therapist was unclear. A random sample of physician patients approximately equal in number to the chiropractic patient group was made. Efforts were made to interview each of these patients in his own home. A questionary was designed to supply data on (1) the type of practitioner visited, the number of visits, treatments used, and the source of referral; (2) patient satisfaction with the therapist and the care received; (3) the degree of functional improvement achieved; (4) the patient’s attitudes toward the medical profession; and (5) the general level of patient hypochondria. We used the technique developed by Bush4 to estimate the functional status of the patient prior to his injury (Tl), at the time of the first visit to a therapist (T2), and at the point of the interview (Ta). These functional levels were computed by combining, three scores-the patient’s degree of body movement, travel and confinement, and activity for each point in time. These values were converted to a continuous scale from which ratios could be derived to compare the function at one point in time in terms of that of another. In the ratio used,
(T3- T2)
(Tl-T2) the numerator measures the extent of improved function after treatment and the denominator reflects the amount of disability imposed by the injury. The entire ratio then reflects the degree to which therapy improved function, relative to the severity of the disability produced by the injury. The higher the ratio, the more effective the treatment. (In using this ratio, we elected to omit six chiropractor patients and one physician patient who exhibited perfect functional scores at all three points in time.) Questions on the patients’ attitudes toward the traditional medical-care system and the medical profession were adapted from scales developed by Hulka et a15 to assess perceptions about professionalism, cost and convenience, and personal qualifications. The only alteration was the substitution of physician " for " doctor " in several to avoid questions any confusion in the patient’s mind with "
chiropractors. The hypochondria scale used was developed by Pilowsky6 and analyses three factors of hypochondria: (1) disease phobia, (2) bodily preoccupation, and (3) degree of conviction about the presence of
a
TABLE II—CHARACTERISTICS
OF PHYSICIAN AND CHIROPRACTOR PATIENTS
To look for possible selection bias, those patients who could not be interviewed but for whom data were available from Workmen’s Compensation records were compared to the respondents. These data included the source of care, and thus we were able to compare chiropractor and physician non-respondents with their respective respondent groups. There was no significant difference in the sex ratio or marital status between respondents and non-respondents among either the chiropractic or medical patients. Nor was there any difference in age among the medical patients; however, among the chiropractic patients the respondent5’ : average age was 6 years more than that of the non-respondents, a significant difference at the 0-05 level by t-test. The data presented in the remainder of this paper will deal only with respondents. Table 11 summarises the demographic characteristics of the respondents. There were no statistically significant differences between respondents treated by physicians and chiropractors with regard to age, educational background, marital status, race,
sex,
TABLE III-TREATMENT AND EFFECTIVENESS
serious disease.
RESULTS
As shown in table I, at least 30% of persons suffering from neck and/or back injuries during the sixmonth period from July to December, 1972, consulted someone other than a medical doctor. This proportion was slightly larger for the geographically defined target area of the study, probably because of the clustering of chiropractors and osteopaths in the more urban areas. Of the 145 physician patients 110 (76%) were interviewed; 10 patients sampled, refused to participate; 25 either had moved from the area or could not be located. For the chiropractor patients, 122 of the 147 in the sample (84%) were interviewed-5 refused and 20 could not be found. The overall response-rate for the study was 80%. This left a study sample of 110 M.D. patients and 122 j.c.
patients.
* By t-test unless otherwise indicated. t Omits 6 D.C. patients and 1 M.D. patient who had perfect functional scores at Ti, T,, and T,.
1335
income, attitudes towards the medical profession,
TABLE V-OUTCOME ACCORDING TO INTENSITY ’OF THERAPY
or
hypochondria. Of the 110 patients who saw a physician, 60 consulted general practitioners and 50 saw a specialist. Physician patients were most likely to have been referred by a fellow worker or by another practitioner; most of the chiropractor patients were either selfreferred or referred by a relative or fellow worker. Table ill compares the extent of treatment and functional-status changes achieved by the physicians and chiropractors. Generally, chiropractors required almost twice as many visits of their patients as did physicians. The mean number of physician visits This was 7-3, compared to 12.8 for chiropractors. is a significant difference. On the other hand, mean duration of treatment was significantly longer for M.D. patients-9-3 weeks as opposed to only 6.5. The physicians thus averaged 1-2 visits per week compared to 2.5 for chiropractors. Functional status of both groups of patients did not differ significantly in terms of their initial and final levels. However, those who saw a physician were significantly more disabled at the time of their first visit than were chiropractic patients. There was some variation in the change in functional status achieved by the different therapists. On the basis of the ratio of improvement previously defined, the TABLE IV-NUMBER OF VISITS TO THERAPIST AND DURATION OF TREATMENT BY FUNCTIONAL STATUS AT TIME OF FIRST VISIT
were somewhat less effective, with a mean ratio of 0.86 compared with 0-92 for the chiropractors. It should be noted that this ratio omits 6 chiropractor patients and 1 physician patient who reported perfect functional scores consistently across Ti, T2, and T3 levels. Table iv shows the difference in the chiropractors’ and physicians’ treatment schedules, according to the disability of their patients. The more severely disabled M.D. patients had a statistically significantly greater number of visits for a longer period of time than did the less severely disabled M.D. patients. This was not true for chiropractor patients. The difference in number of visits by chiropractor and M.D. patients was significant at the 0.001 level; the difference in duration of care was significant at the 0-04 level. Table v compares the outcome of care with these same measures of therapeutic intensity.. For chiropractor patients, there is a tendency for those who showed the least improvement to have had the most therapy. This was statistically significant in terms of number of visits, but not in terms of duration of treatment. Among M.D. patients there were significant
physicians
I .
Omits 1 M.D.
I
I
B
patient who had perfect functional
and T a. t Omits 6 D.c. patients who had
perfect functional
scores at
T 1>
T"
T 1> T,, and
scores at
Ts. e.
variations but in no specific direction. Once again the differences between practitioners were statistically significant. For number of visits the significance level for duration, <0.03. was <0-001; In these analyses the seven patients mentioned above who showed consistently perfect functional scores over time were again omitted. Treatment employed varied among practitioners. Physicians used medication, heat, braces or casts, physical therapy, and exercises, in that order. They tended to use surgery, physical therapy, and braces with the more disabled patients. Chiropractors used manipulation, heat, braces or casts, and exercises. With the more disabled patients, they were more likely to use heat and braces. Chiropractors used medication for only about 5 % of their patients. The patients were specifically asked about their sense of satisfaction with their therapist and his treatment (table vi). There was a statistically significant difference in the chiropractor patients’ perception of the degree to which they were made to feel welcome. The chiropractors’ patients were also significantly more satisfied with the explanation they received about their problem and its treatment. DISCUSSION
Given
the
emotional
climate
of
the
medical
community toward chiropractors, a dispassionate discussion of M.D. and chiropractic effectiveness is diffiTABLE VI-MEASURES OF PATIENT SATISFACTION
*
Differences between
chi-square.
M.D.
and
D.c.
patients significant
at p <
0-05
by
1336
When a medical-care journal recently presented an article reviewing the experience of New York’s Medicaid program in reimbursing chiropractors for their services,’ a flurry of criticism and explanation ensued.8.9 This study compares the care given by chiropractors and physicians in terms of the outcomes achieved for 232 similarly disabled cult
at
best.
patients. There are, however, several limitations on the study. The design is retrospective; it relies on the patient’s recall of his functional status at several points in time over the previous year. Although there is no reason to suspect any systematic bias to favour one type of provider over another, this possibility must be considered. Because chiropractors utilise a diagnostic nomenclature different from physicians, it was not possible to pair individual cases to assure their comparability. There is some suggestion, moreover, that those patients with more severe disabilities tended to consult physicians in preference to chiropractors. In the same vein, the pattern of a lower number of physician visits by patients failing to improve (table v) can be accounted for by assuming that patients failing to respond quickly tended to discontinue therapy before a beneficial result could be achieved. Finally, the number of patients examined is small. Significant medical problems which were remediable only by surgical intervention could have been missed just on the basis of sample size. None the less, the results suggest that by two measures of outcome-patient’s perception of improvement in functional status and patient satisfaction-the chiropractors have been as effective with the patients they treated as were the physicians. This may be in part attributable to good self-selection by the patient in his choice of therapist. Moreover, it cannot be assumed that patients who choose to utilise a chiropractor are more likely to suffer psychosomatic problems. At least from the data obtained in this study, there was no difference in the hypochondria scores of chiropractor and physician patients. Nor can we attribute the use of a chiropractor to feelings of distrust or animosity toward physicians, for the data suggest no difference in attitudes between the two groups of patients. The selection of chiropractors by their patients seems to be based on other values and, at least from the patient’s perspective, seems to have been successful. The chiropractors generated more patient satisfaction than did the physicians, particularly in regard to the patient’s response to the personality of the practitioner and his ability to explain the problem and its treatment. It is not our purpose to debate the proposition that chiropractic is or is not a legitimate method of therapy. Certainly the articles in the medical literature challenging its scientific basis and its academic credentials cannot be refuted by a single small retrospective study. Rather, we would suggest that there are valuable lessons which the medical profession might learn. These are mainly in the area of medical techniques for communicating with patients. On the basis of our study and others,to-12 it appears that the chiropractor may be more attuned to the total needs of the patient than is his medical counterpart.
chiropractor does not seem hurried. He uses language patients can understand. He gives them sympathy, and he is patient with them. He does not take a superior attitude toward them. In summary, it is an egalitarian relationship rather than a superordinate/subordinate relationship. Entralgp claims the major variables that explain why some patients prefer chiropractors can be found in the socioemotional aspects of the patient’s relationship with his doctor." Balint describes the most important element in all remedies as an emotionally satisfactory relationship between the invalid and his doctor.’4 Other workers have indicated the importance of the doctorpatient relationship to achieve effective therapy, especially in improved patient compliance."-"
The
CONCLUSION
The facts revealed in this study underscore the powerful potential for the doctor-patient relationship in effective treatment, whether in chiropractic or
traditional medicine. This factor should be recognised and accepted as an essential part of that process. This study suggests that, although the theoretical basis of chiropractic is still unsubstantiated by traditional scientific evidence, none the less the intervention of a chiropractor in problems around neck and spine injuries was at least as effective as that of a physician, in terms of -restoring the patient’s function and satisfying the patient. Such a study illustrates the difficulties of measuring, or even defining, good-quality care. It may well be that any practitioner, regardless of his discipline, who is responsive to the emotional needs of the patient could achieve equal results; this is beyond the scope of the research described here. We suggest that the results of this study indicate a need for further research, preferably in the form of a randomised clinical trial, to establish the validity of chiropractic care. As the storm clouds darken in the clash between organised medicine and chiropractic, it is imperative that definitive data replace impassioned statements. Perhaps the new regulations proposed under PL 92-603 will provide the means to conduct such studies. Requests for reprints should be addressed to R. L. K., University of Utah Medical Center, Department of Family and Community Medicine, 50 North Medical Drive, Salt Lake
City, Utah 84132. REFERENCES 1. 2. 3. 4. 5.
Kuby, A. M. Master’s thesis, University of Chicago, 1965. Ballantine, H. T., Jr. New Engl. J. Med. 1972, 286, 237. Crelin, E. S. Am. Sci. 1973, 61, 574. Bush, J. W. Am. J, publ. Hlth, 1971, 61, 2362. Hulka, B. S., Zyzanski, S. J., Cassel, J. C., Thompson, S. J. Med.
Care, 1970, 8, 428. 6. Pilowsky, I. Br. J. Psychiat. 1967, 113, 89. 7. Dintenfass, J. Med. Care, 1973, 11, 40. 8. Myers, B. A., Badgley, R. F., Sabatier, J. A., Jr. ibid. p. 436. 9. Bellin, L. E. ibid. p. 441. 10. Stanford Research Institute. Chiropractic in California. Los Angeles, 1969. 11. Koos, E. in Patients, Physicians, and Illness (edited by E. G. Jaco); p. 113. Glencoe, 1958. 12. Cobb, B. Psychol. Bull. 1954, 3, 339. 13. Entralgo, P. L. Doctor and Patient. New York, 1969. 14. Balint, M. Doctor, Patient, and Illness. New York, 1957. 15. Kane, R. L., Deuschle, K. W. Med. Care, 1967, 5, 260. 16. Francis, V., Korsch, B. M., Morris, M. J. New Engl. J. Med. 1969, 280, 535. 17. Bloom, S. W. The Doctor and His Patient. New York, 1965.
legacy of the Greek humoral theory and the Hippocratic-Galenic tradition.8 Problems associated with the organisation and delivery of health care in rural Iran. These problems relate to the vacuum in rural health care, particularly the paucity of physicians for referral or supervision. Problems associated with village social structure.
B.
C.
The difficulties with rival factions are in this Also, personality characteristics of the category. v.H.w. (such as the desire to move up from village to city, and concern with status, particularly the accoutrements of the physician, such as white coat, stethoscope, and hypodermic syringes) are important factors influencing his or her effectiveness. CONCLUSION
On the basis of our limited experience in Iran, believe that the Chinese barefoot doctor is not easily transplantable to Iranian soil, and that auxiliary
we
Occasional
Survey
MANIPULATING THE PATIENT A COMPARISON OF THE EFFECTIVENESS OF PHYSICIAN AND CHIROPRACTOR CARE
ROBERT L. KANE CRAIG LEYMASTER DONNA OLSEN F. ROSS WOOLLEY F. DAVID FISHER Department of Family and Community Medicine, University of Utah College of Medicine, Salt Lake City, Utah 84132
Patients identified through Workmen’s Compensation records as having been treated for back or spinal problems by a chiropractor (122) or a physician (110) were interviewed to determine their functional status before and after the accident and their satisfaction with the care received. In terms of both the patients’ perception of improvement in functional status and patient satisfaction, the chiropractors appear to have been as effective with the patients they treated as were the physicians. The two groups of patients were not significantly different with regard to age, sex, race, education, marital status, income, hypochondria, or attitudes about the medical profession in general.
Sum ary
INTRODUCTION
THE medical
profession’s disdain for chiropractic has existed since the first emergence of the practice at the end of the nineteenth century. None the less, the public turns to chiropractors for assistance in ever more substantial numbers. Kuby cites two studies from the mid-1950s which suggest that 5-7% of the families surveyed had consulted a chiropractor during the previous year. Over 16% of the respondents expressed a willingness to use such a practitioned 1 Despite the opposition of organised medicine, chiropractors are now eligible for reimbursement under Medicare as a result of PL 92-603. Ballantine represents the position of many physicians 2: "The inclusion of chiropractic in any health care
in Iran must take into of the rural situation. There is
training
<
account a
great dt
REFERENCES 1. 2.
3. 4. 5. 6. 7.
8.
Sidel, V. W. New Engl. J. Med. 1972, 286, 1292. Sidel, V. W. Int. J. Hlth Serv. 1972, 2, 385. Ronaghy, H. A., Cahill, K., Baker, T. D. J. Am. med. Ass. 1974, 227, 538. Ronaghy, H. A., Solter, S. L. Lancet, 1973, ii, 427. Gringras, G., Geekie, D. A. Can. med. Ass. J. 1973, 109, 150A. Horn, J. Away With All Pests. New York, 1972. Pickowicz, P. G. in Modern China and Traditional Chinese Medicine (edited by G. B. Ruse); p. 124. Springfield, Illinois, 1973. Livingston, R. B., Mahloudji, M. Pah. med. J. 1970, 3, 38 (abstr.)
program, public or private, is not in the public interest. There is no reason to believe that further studies of chiropractic would bring forth new facts to negate the findings previously published by knowledgeable investigators of
unquestionable integrity."
Ironically, there is a scarcity of scientific data the validity of chiropractic theory or the effectiveness of chiropractic therapy. The first experimental study of the basis for the theory of vertebral manipulation to be published in a recognised scientific journal appeared in 1973.3 However, the public continues to find solace in the services offered by these practitioners, as evidenced by the continued use of their services. In recognition of this public support and prompted by the current medical furore over the Medicare regulations, we felt it appropriate to attempt an evaluation of the effectiveness of chiropractic treatment, regardless of the theoretical validity of the methods. If chiropractors are able to improve their patients’ functional levels, as judged by the patients on
themselves, this evidence would be
a
first step in
bringing factual data and rational discussion overheated subject.
to
an
METHODS
To establish our sample, we reviewed all claims of the Utah State Insurance Fund (Workmen’s Compensation) between July and December, 1972, to identify neck and back injuries (table I). From these, those patients living within an hour’s travelling time from the university were listed. Workmen’s Compensation permits the injured worker to select his therapist from among physicians, TABLE I-UTAH STATE INSURANCE FUND WORKMEN’S COMPENSATION NECK AND BACK INJURIES, JULY-DECEMBER, 1972 —————————————————————.———————————,————————————————
*
145
randomly sampled for this study.
t Included in study.
1334
osteopaths, and chiropractors. For the study period and geographical area specified, records were identified for 147 chiropractor (D.C.) patients and 336 medical (M.D.) patients; 13 patients had used osteopaths and 44 had consulted both a physician and a chiropractor. For 67 cases the type of therapist was unclear. A random sample of physician patients approximately equal in number to the chiropractic patient group was made. Efforts were made to interview each of these patients in his own home. A questionary was designed to supply data on (1) the type of practitioner visited, the number of visits, treatments used, and the source of referral; (2) patient satisfaction with the therapist and the care received; (3) the degree of functional improvement achieved; (4) the patient’s attitudes toward the medical profession; and (5) the general level of patient hypochondria. We used the technique developed by Bush4 to estimate the functional status of the patient prior to his injury (Tl), at the time of the first visit to a therapist (T2), and at the point of the interview (Ta). These functional levels were computed by combining, three scores-the patient’s degree of body movement, travel and confinement, and activity for each point in time. These values were converted to a continuous scale from which ratios could be derived to compare the function at one point in time in terms of that of another. In the ratio used,
(T3- T2)
(Tl-T2) the numerator measures the extent of improved function after treatment and the denominator reflects the amount of disability imposed by the injury. The entire ratio then reflects the degree to which therapy improved function, relative to the severity of the disability produced by the injury. The higher the ratio, the more effective the treatment. (In using this ratio, we elected to omit six chiropractor patients and one physician patient who exhibited perfect functional scores at all three points in time.) Questions on the patients’ attitudes toward the traditional medical-care system and the medical profession were adapted from scales developed by Hulka et a15 to assess perceptions about professionalism, cost and convenience, and personal qualifications. The only alteration was the substitution of physician " for " doctor " in several to avoid questions any confusion in the patient’s mind with "
chiropractors. The hypochondria scale used was developed by Pilowsky6 and analyses three factors of hypochondria: (1) disease phobia, (2) bodily preoccupation, and (3) degree of conviction about the presence of
a
TABLE II—CHARACTERISTICS
OF PHYSICIAN AND CHIROPRACTOR PATIENTS
To look for possible selection bias, those patients who could not be interviewed but for whom data were available from Workmen’s Compensation records were compared to the respondents. These data included the source of care, and thus we were able to compare chiropractor and physician non-respondents with their respective respondent groups. There was no significant difference in the sex ratio or marital status between respondents and non-respondents among either the chiropractic or medical patients. Nor was there any difference in age among the medical patients; however, among the chiropractic patients the respondent5’ : average age was 6 years more than that of the non-respondents, a significant difference at the 0-05 level by t-test. The data presented in the remainder of this paper will deal only with respondents. Table 11 summarises the demographic characteristics of the respondents. There were no statistically significant differences between respondents treated by physicians and chiropractors with regard to age, educational background, marital status, race,
sex,
TABLE III-TREATMENT AND EFFECTIVENESS
serious disease.
RESULTS
As shown in table I, at least 30% of persons suffering from neck and/or back injuries during the sixmonth period from July to December, 1972, consulted someone other than a medical doctor. This proportion was slightly larger for the geographically defined target area of the study, probably because of the clustering of chiropractors and osteopaths in the more urban areas. Of the 145 physician patients 110 (76%) were interviewed; 10 patients sampled, refused to participate; 25 either had moved from the area or could not be located. For the chiropractor patients, 122 of the 147 in the sample (84%) were interviewed-5 refused and 20 could not be found. The overall response-rate for the study was 80%. This left a study sample of 110 M.D. patients and 122 j.c.
patients.
* By t-test unless otherwise indicated. t Omits 6 D.C. patients and 1 M.D. patient who had perfect functional scores at Ti, T,, and T,.
1335
income, attitudes towards the medical profession,
TABLE V-OUTCOME ACCORDING TO INTENSITY ’OF THERAPY
or
hypochondria. Of the 110 patients who saw a physician, 60 consulted general practitioners and 50 saw a specialist. Physician patients were most likely to have been referred by a fellow worker or by another practitioner; most of the chiropractor patients were either selfreferred or referred by a relative or fellow worker. Table ill compares the extent of treatment and functional-status changes achieved by the physicians and chiropractors. Generally, chiropractors required almost twice as many visits of their patients as did physicians. The mean number of physician visits This was 7-3, compared to 12.8 for chiropractors. is a significant difference. On the other hand, mean duration of treatment was significantly longer for M.D. patients-9-3 weeks as opposed to only 6.5. The physicians thus averaged 1-2 visits per week compared to 2.5 for chiropractors. Functional status of both groups of patients did not differ significantly in terms of their initial and final levels. However, those who saw a physician were significantly more disabled at the time of their first visit than were chiropractic patients. There was some variation in the change in functional status achieved by the different therapists. On the basis of the ratio of improvement previously defined, the TABLE IV-NUMBER OF VISITS TO THERAPIST AND DURATION OF TREATMENT BY FUNCTIONAL STATUS AT TIME OF FIRST VISIT
were somewhat less effective, with a mean ratio of 0.86 compared with 0-92 for the chiropractors. It should be noted that this ratio omits 6 chiropractor patients and 1 physician patient who reported perfect functional scores consistently across Ti, T2, and T3 levels. Table iv shows the difference in the chiropractors’ and physicians’ treatment schedules, according to the disability of their patients. The more severely disabled M.D. patients had a statistically significantly greater number of visits for a longer period of time than did the less severely disabled M.D. patients. This was not true for chiropractor patients. The difference in number of visits by chiropractor and M.D. patients was significant at the 0.001 level; the difference in duration of care was significant at the 0-04 level. Table v compares the outcome of care with these same measures of therapeutic intensity.. For chiropractor patients, there is a tendency for those who showed the least improvement to have had the most therapy. This was statistically significant in terms of number of visits, but not in terms of duration of treatment. Among M.D. patients there were significant
physicians
I .
Omits 1 M.D.
I
I
B
patient who had perfect functional
and T a. t Omits 6 D.c. patients who had
perfect functional
scores at
T 1>
T"
T 1> T,, and
scores at
Ts. e.
variations but in no specific direction. Once again the differences between practitioners were statistically significant. For number of visits the significance level for duration, <0.03. was <0-001; In these analyses the seven patients mentioned above who showed consistently perfect functional scores over time were again omitted. Treatment employed varied among practitioners. Physicians used medication, heat, braces or casts, physical therapy, and exercises, in that order. They tended to use surgery, physical therapy, and braces with the more disabled patients. Chiropractors used manipulation, heat, braces or casts, and exercises. With the more disabled patients, they were more likely to use heat and braces. Chiropractors used medication for only about 5 % of their patients. The patients were specifically asked about their sense of satisfaction with their therapist and his treatment (table vi). There was a statistically significant difference in the chiropractor patients’ perception of the degree to which they were made to feel welcome. The chiropractors’ patients were also significantly more satisfied with the explanation they received about their problem and its treatment. DISCUSSION
Given
the
emotional
climate
of
the
medical
community toward chiropractors, a dispassionate discussion of M.D. and chiropractic effectiveness is diffiTABLE VI-MEASURES OF PATIENT SATISFACTION
*
Differences between
chi-square.
M.D.
and
D.c.
patients significant
at p <
0-05
by
1336
When a medical-care journal recently presented an article reviewing the experience of New York’s Medicaid program in reimbursing chiropractors for their services,’ a flurry of criticism and explanation ensued.8.9 This study compares the care given by chiropractors and physicians in terms of the outcomes achieved for 232 similarly disabled cult
at
best.
patients. There are, however, several limitations on the study. The design is retrospective; it relies on the patient’s recall of his functional status at several points in time over the previous year. Although there is no reason to suspect any systematic bias to favour one type of provider over another, this possibility must be considered. Because chiropractors utilise a diagnostic nomenclature different from physicians, it was not possible to pair individual cases to assure their comparability. There is some suggestion, moreover, that those patients with more severe disabilities tended to consult physicians in preference to chiropractors. In the same vein, the pattern of a lower number of physician visits by patients failing to improve (table v) can be accounted for by assuming that patients failing to respond quickly tended to discontinue therapy before a beneficial result could be achieved. Finally, the number of patients examined is small. Significant medical problems which were remediable only by surgical intervention could have been missed just on the basis of sample size. None the less, the results suggest that by two measures of outcome-patient’s perception of improvement in functional status and patient satisfaction-the chiropractors have been as effective with the patients they treated as were the physicians. This may be in part attributable to good self-selection by the patient in his choice of therapist. Moreover, it cannot be assumed that patients who choose to utilise a chiropractor are more likely to suffer psychosomatic problems. At least from the data obtained in this study, there was no difference in the hypochondria scores of chiropractor and physician patients. Nor can we attribute the use of a chiropractor to feelings of distrust or animosity toward physicians, for the data suggest no difference in attitudes between the two groups of patients. The selection of chiropractors by their patients seems to be based on other values and, at least from the patient’s perspective, seems to have been successful. The chiropractors generated more patient satisfaction than did the physicians, particularly in regard to the patient’s response to the personality of the practitioner and his ability to explain the problem and its treatment. It is not our purpose to debate the proposition that chiropractic is or is not a legitimate method of therapy. Certainly the articles in the medical literature challenging its scientific basis and its academic credentials cannot be refuted by a single small retrospective study. Rather, we would suggest that there are valuable lessons which the medical profession might learn. These are mainly in the area of medical techniques for communicating with patients. On the basis of our study and others,to-12 it appears that the chiropractor may be more attuned to the total needs of the patient than is his medical counterpart.
chiropractor does not seem hurried. He uses language patients can understand. He gives them sympathy, and he is patient with them. He does not take a superior attitude toward them. In summary, it is an egalitarian relationship rather than a superordinate/subordinate relationship. Entralgp claims the major variables that explain why some patients prefer chiropractors can be found in the socioemotional aspects of the patient’s relationship with his doctor." Balint describes the most important element in all remedies as an emotionally satisfactory relationship between the invalid and his doctor.’4 Other workers have indicated the importance of the doctorpatient relationship to achieve effective therapy, especially in improved patient compliance."-"
The
CONCLUSION
The facts revealed in this study underscore the powerful potential for the doctor-patient relationship in effective treatment, whether in chiropractic or
traditional medicine. This factor should be recognised and accepted as an essential part of that process. This study suggests that, although the theoretical basis of chiropractic is still unsubstantiated by traditional scientific evidence, none the less the intervention of a chiropractor in problems around neck and spine injuries was at least as effective as that of a physician, in terms of -restoring the patient’s function and satisfying the patient. Such a study illustrates the difficulties of measuring, or even defining, good-quality care. It may well be that any practitioner, regardless of his discipline, who is responsive to the emotional needs of the patient could achieve equal results; this is beyond the scope of the research described here. We suggest that the results of this study indicate a need for further research, preferably in the form of a randomised clinical trial, to establish the validity of chiropractic care. As the storm clouds darken in the clash between organised medicine and chiropractic, it is imperative that definitive data replace impassioned statements. Perhaps the new regulations proposed under PL 92-603 will provide the means to conduct such studies. Requests for reprints should be addressed to R. L. K., University of Utah Medical Center, Department of Family and Community Medicine, 50 North Medical Drive, Salt Lake
City, Utah 84132. REFERENCES 1. 2. 3. 4. 5.
Kuby, A. M. Master’s thesis, University of Chicago, 1965. Ballantine, H. T., Jr. New Engl. J. Med. 1972, 286, 237. Crelin, E. S. Am. Sci. 1973, 61, 574. Bush, J. W. Am. J, publ. Hlth, 1971, 61, 2362. Hulka, B. S., Zyzanski, S. J., Cassel, J. C., Thompson, S. J. Med.
Care, 1970, 8, 428. 6. Pilowsky, I. Br. J. Psychiat. 1967, 113, 89. 7. Dintenfass, J. Med. Care, 1973, 11, 40. 8. Myers, B. A., Badgley, R. F., Sabatier, J. A., Jr. ibid. p. 436. 9. Bellin, L. E. ibid. p. 441. 10. Stanford Research Institute. Chiropractic in California. Los Angeles, 1969. 11. Koos, E. in Patients, Physicians, and Illness (edited by E. G. Jaco); p. 113. Glencoe, 1958. 12. Cobb, B. Psychol. Bull. 1954, 3, 339. 13. Entralgo, P. L. Doctor and Patient. New York, 1969. 14. Balint, M. Doctor, Patient, and Illness. New York, 1957. 15. Kane, R. L., Deuschle, K. W. Med. Care, 1967, 5, 260. 16. Francis, V., Korsch, B. M., Morris, M. J. New Engl. J. Med. 1969, 280, 535. 17. Bloom, S. W. The Doctor and His Patient. New York, 1965.