Chiropractors like to tell people that they have sufficient training to make appropriate diagnoses and to refer people for medical treatment when needed. I have tested this assertion in several ways. This article reports on five phone calls and six visits involving a total of nine chiropractors. During most of these, I complained about conditions whose treatment is not within chiropractic’s legitimate scope. In 1990, I telephoned five local offices to test whether the chiropractor would encourage people with serious medical problems to come for chiropractic care. All of them did so. I subsequently visited one of them who diagnosed several problems I didn’t have—and another who said that my x-ray films (which were normal) revealed serious pathology. In recent years, I have made four office visits in which I described the classic symptoms of a serious medical problem. In each case, the chiropractor missed the diagnosis and failed to make an appropriate referral. Here are the details.
During my first call to a chiropractic office, I told the receptionist that I had recently been diagnosed with ulcers and was supposed to be on medication. I wondered whether they could help me without drugs. She replied that she couldn’t tell me for sure, because “every patient is different,” but that they had treated ulcers before and would be glad to discuss it further if I came for an evaluation.
During my call to the second chiropractic office, I said that I had recently been diagnosed with diabetes and was supposed to be taking insulin but desired alternative treatment. The doctor then informed me that, “every patient is different” but that he had treated diabetes before successfully and would be glad to help me if I came to see him. He was careful not to tell me to stop taking my insulin but that with extensive therapy he might decrease or even eliminate the need for insulin. He added that while all therapy carried some risk, the medical treatment certainly was riskier because it involved putting something in my body.
During a call to another chiropractic office, I said that I had been diagnosed with a form of cancer known as leukemia and had been advised to undergo chemotherapy, but that a friend had indicated that chiropractors could treat cancer without drugs. The chiropractor responded that, “every patient is different” but that chiropractic treatment in conjunction with chemotherapy might be helpful. He suggested that I come in for a “free spinal evaluation.”When I asked what type of therapy he could offer, he repeated that ” every patient is different” and that he would need to evaluate me individually.
During a call to another chiropractic office, I told the receptionist that my wife had suffered from recurrent kidney infections for the past several years and that while the doctors were able to treat these with antibiotics, they were not able to prevent them and that we had grown frustrated with this and wanted a different form of treatment. She replied that she could not say for sure but that she thought that they had helped with similar problems and that in her own experience, her sinus problems had been helped with chiropractic. She recommended that my wife come for a free spinal exam so the doctor could determine whether he would be able to help her.
During a call to another chiropractic office, I told the receptionist that I was a recovering alcoholic and had suffered from chronic pancreatitis for approximately 2 years with only minimal relief of my symptoms from medical management. She stated that she couldn’t tell me for sure but that their office had successfully treated this disease in the past and would be glad to see me for a “free initial exam” after which a decision could be made. She went on to tell me that the chiropractor was a “specialist”—a “chiropractic orthopedist”—which meant that he had ” the same knowledge as an orthopedic surgeon” but was able to take care of problems without surgery. I didn’t ask what that had to do with pancreatitis.
A few weeks later, I visited this chiropractor for a free examination. His waiting room wall displayed several plaques used for practice-building purposes. One asked patients to refer friends. Another offered a free year of chiropractic care for the whole family of the patient who referred the most business. A third was a chart purporting to show that chiropractors had more hours of education than did medical doctors. (Such charts are misleading because they don’t take into account that the quality of medical teaching is vastly superior or that most medical doctors take three or four additional years of postgraduate training before going out into practice.) After greeting me in the waiting room, this chiropractor took me into into his office and left me alone for a few minutes. On one wall was a bookcase that held many standard medical books similar as well as chiropractic texts. Another wall was covered with framed documents and certificates from chiropractic sources, most of which pertained to . brief postgraduate courses at a chiropractic school. I did not see any type of college diploma. *(I wondered whether he routinely leaves people in his office with the hope that they will be impressed with his vast array of certificates and medical library.) When the chiropractor returned and asked what he could do to help me, I replied that about six months previously, I had injured my back while moving furniture and was by a hospital emergency room physician who diagnosed “lumbar strain,” said my x-rays were normal, and prescribed Motrin and Flexeril. I told the chiropractor that although the pain improved, it still bothered me from time to time. I also indicated that I had been water skiing one week before and that my back had been hurting ever since. After briefly asking me about my medical history, he led me into his examining room. After I disrobed, he commented that my boots showed uneven wear which indicated that my feet were flat and that shoe inserts could help me. After taking my blood pressure, he asked me to stand facing the wall and examined my spine by feeling, probing, and asking me whether that hurt. I randomly indicated that several areas were tender but stressed that the tenderness was very mild. Following this exam, he said that he had located torn ligaments and torn muscles in my back. Next he had me lie face-up on the table so he could move my legs and toes in various ways and test my reflexes, after which he stated that I had several pinched nerves in the low back on both sides. He told me that he could definitely help and that I should return the next day with my x-ray films from the hospital, at which time he could begin treatment. I stated that the x-rays had already been read as negative and asked whether it was necessary to obtain them. He replied that medical doctors read them “differently,” looking only for things like cancer and not the subtle changes that chiropractors are able to see. Although my “back injury” was completely fictitious, the chiropractor confirmed my alleged diagnosis of torn ligaments and muscles and found “pinched nerves” in addition.
A few weeks later, I visited another office with a made-up story about low back pain that had persisted since I had helped a friend move furniture three weeks previously. I said that I had been evaluated at a walk-in medical clinic where an on-call physician had examined, ordered x-ray films that he had interpreted as normal, diagnosed a lumbar strain, and prescribed pain-reliever and muscle-relaxanr drugs. I told the chiropractor that my symptoms had improved but had not completely resolved and that a friend had urged me to see a chiropractor. Before visiting the chiropractor, I had x-rays taken of my back that I and a radiologist friend interpreted as normal. I brought these films with me to the chiropractic clinic. After a short wait, I was taken to the doctors private office and left alone—possibly (as with the previous chiropractor) to contemplate the extensive medical library and framed documents. Then the chiropractor led me to his examing room, where a young woman who identified herself as a chiropractic technician. performed orthopedic and neurologic type tests and asked whether anything she did was painful. I indicated that I wasn’t having much pain. The doctor then examined my spine while the technician recorded findings of extensive pathology that he reported at each level of the spine. Then, with a sense of urgency, he instructed the technician to prepare me for a series of x-rays that included a full-spine film. I said that I had come only for an initial exam and wasn’t sure that I was willing to undergo additional x-rays. I then asked if there was something abnormal about the x-rays that I had brought with me. He then looked me in the eye, said “You bet there is!” and asked me to return the following day for a “counseling session” to review the results of my films and exam and to discuss a treatment plan. (I did not return.)
In October 2002, I visited a chiropractic “wellness” center pretending to be an uninsured real estate agent who was suffering from impotence. I first telephoned and asked the chiropractor whether she thought she could help me. During this conversation, she was cautious by encouraging and stated that the best thing to do was to come for a visit to determine if I were a candidate for chiropractic care. Shortly after arriving in her office, I was taken to an examining room, and shortly thereafter the chiropractor entered the room and introduced herself. After I described sexual problem, she asked a few brief questions and, without having me remove my shirt, felt my back with her hand. Moments later, she confidently stated that she had located a spinal abnormality that was very likely the source of my problem. I asked several times whether it would be helpful to examine my genital area, but she insisted that this was not necessary at this time. She recommended that I undergo chiropractic adjustment and, while she could not guarantee results, she felt that there was a strong probability that I would benefit from this therapy. She was willing to begin treatment immediately. I expressed skepticism and indicated that I would consider her recommendations and return at a later date if decided to proceed.
About six months later, having shaved my beard, I returned to the clinic without an appointment, identifying myself as an uninsured construction worker with episodic left-sided chest pain that radiated to my left shoulder and upper arm. I stated that the pain was frequently associated with shortness of breath and often occurred during my job as a framing carpenter. I also indicated that I was a 2-pack-a-day smoker for 20 or so years and a heavy drinker. Any competent practitioner should suspect that my symptoms were caused by insufficient blood flow to the heart that would place the patient at high risk for sudden death. The chiropractor asked several questions related to my symptoms and initially expressed concern that they might be related to my heart. However, after using her hand to feel my left shoulder and shoulder-blade area and the front of my chest, she concluded that some of my ribs were “out,” meaning that the ribs had “lost their normal range of motion” and could possibly be the source of my problem. Then she placed a stethoscope on my breastbone, listened intently for a few seconds, and said, “Your heart sounds OK, I mean its not beating weird.” Based on this finding, she said she was able to rule out cardiac origin of my complaint. She concluded that the “ribs out” were the most likely cause of my symptoms and recommended a course of chiropractic therapy at $38 per visit to return the ribs to their normal “range of motion.”
In November 2003, I visited another chiropractor and described myself as an uninsured construction worker who had right lower abdominal pain associated with nausea. I indicated that these symptoms had started two days earlier and were worse that morning. In the examining room, the doctor asked me to remove my coat but not my flannel work shirt or undershirt and then examined my back. Within seconds, he stated that there was a “shift” as he palpated my lower thoracic region. He spoke very rapidly and mentioned “muscle spasm,” and “pinched nerve” and continued to refer to a “shift.” He also stated that their was a virus going around that could also be the source of my problem. Next he asked me to bend over and touch my toes and noted that there was no evidence of scoliosis. Finally, he felt my neck and lower-jaw area while stating that this was the area in which he specialized and that there might be problems in this area as well. He concluded that a few treatments might resolve my problem and invited me to lay face-down on a table for a “little adjustment.” I thanked him and indicated that I wanted to think about the situation before deciding. At no point during this visit did he ask about my nausea or consider whether I had any fever. Nor did he inquire about any previous surgery or examine by abdomen for tenderness. in short, he did not appear to consider the possibility of acute appendicitis, a condition that could become life-threatening if not diagnosed before the appendix ruptures.
Later the same day, I walked in without an appointment to another chiropractic office and told the young man at the desk that I was having pain in the right side of my abdomen and wondered if I could get checked out. He said yes and had me fill out a health questionnaire. While completing the paperwork, I asked the young man whether he was the doctor and he said yes. I then said that he looked too young to be a doctor, and he laughed and said he was older than he looked. While leading me to the examining room, he asked whether I had ever had my appendix removed and I said no. He suggested that appendicitis was a possibility but that he would probably be able to determine that with his exam. Initially, he felt my abdomen, including the right lower quadrant. Next he asked me to lie face-down and immediately stated that my right leg was shorter than the left. He asked whether I carried anything in my pocket and I said yes. He then stated that this could be the problem and that the weight of my wallet could be affecting my right hip causing a buildup of lactic acid and leading to what is known as a “side stitch.” He again stated that appendicitis was still a possibility but he wanted to perform spinal x-rays to look further into the problem. While the films were being processed ,he asked me to lie on a different table for what he referred to was “just some therapy.” He applied two adhesive pads to my low back and initiated an electric current which resulted in a tingling sensation in my back. After several minutes, I was led back to the exam room to review my x-ray films, which he said revealed a narrowed disc space in my lower back. He stated that this could be another cause of my pain because a nerve leading to my side could be pinched. He then suggested that an adjustment would be the most conservative treatment option and very well might resolve my problem but that if I had not improved in a day or two that I should seek medical evaluation for possible appendicitis. He again mentioned the “side stitch” and stated that he felt there was a good possibility that an adjustment would help. It apparently did not occur to him that if I actually had appendicitis, a two-day delay could prove fatal.
Dr. Kinsinger is an anesthesiologist in Oklahoma City, Oklahoma.
This article was revised on December 25, 2003.