Skip to main content
Green Shield Canada

Episode 15: Chiropractic in Canada – A Tale of Self-Regulation

In episode 15 (yes, it’s been a while!), host David Willows speaks with Globe & Mail contributors Wayne MacPhail and Paul Benedetti about the schism that exists in the Canadian chiropractic community. It is a cautionary tale on the limits of self-regulation.
And now for something completely indifferent

And now for something completely indifferent

--:--
--:--
Subcribe via iTunesSubcribe Via Google Podcasts

Episode 15 Transcript

[INTRODUCTION]

[0:00:14.9] SM: Hello and welcome to another episode of GSC’s Podcast; And Now For Something Completely Indifferent, where we’ll be discussing the hottest topics and trends in Canadian health benefits. I am the producer and editor, Sarah Murphy.

Before we get started with today’s episode, we would like to remind our listeners that the views expressed in this podcast are those of the individual speaking and not necessarily the views of GSC. We may talk about possibly controversial subjects and therefore, reserve the right to potentially offend some listeners, but are apologizing for it upfront.

You can download this podcast from our website at greenshield.ca\podcast, or subscribe to it from wherever you get your podcasts. We also encourage you to read our publications, the inside story and follow the script, which you can also download from our website. Please be sure to follow the conversation on Twitter and LinkedIn.

Now let’s get started. Today’s episode is hosted by David Willows, GSC’s Chief Innovation and Marketing Officer.

[EPISODE]

[0:01:17.0] SM: Hello, David.

[0:01:17.9] DW: Hi, Sarah. This is an interesting podcast we’re introducing here today. One that comes on top of your legal warning that you always do and you’ve been instructed to do.

We have with us today a couple of writers and contributors to The Globe and Mail and that’s a big deal with us. The topic they’re going to be speaking on is the chiropractic community in Canada. It’s a bit of a harrowing discussion of the things that they research and reported on really over a 15 to 16-year period. We just want to warn listeners, chiropractors will probably not get a big kick out of, or enjoy this particular podcast. Anybody who lives and loves the chiropractor; I know Sarah you go to the chiropractor a lot and I do think you love your chiropractor.

[0:02:11.9] SM: It’s possible, yeah that I do love him.

[0:02:13.6] DW: It’s possible. Some listeners may be made a little uncomfortable by this podcast. It dates back – the reason we’re having these writers in is on November 1st, 2018 they wrote a long-form article in the Globe and Mail, about the state of chiropractic in Canada and specifically about the regulation of chiropractic in Canada.

The reason we invited them in, is because we’re doing a couple of pieces in our Inside Story about self-regulation of health professionals in Canada. For better, for worse, this story and these reporters have become a lightning rod for some of the concerns that probably broader people have and certainly we have about self-regulation in Canada.

We do want to say that we work hard with the chiropractic community. We have a dialogue with them all the time to get someone in for a podcast, to talk a bit about the issues that are raised. We have not been able to achieve that over the last couple months, so we are going to run this podcast without that ability to respond, but we certainly hope and invite folks from that community to come in the future to talk about the issues raised in this particular podcast.

With that warning to listeners –

[0:03:18.3] SM: A good one.

[0:03:19.0] DW: - we are going to go into what we think is a really interesting podcast with some great storytellers.

In the studio today, it is a full house. We have our producer and editor Sarah actually on the wellness bed today, because we have so many people packed in here around the microphones. We have with us writers and contributors to the Globe and Mail. One, Wayne MacPhail, who is also on the side a digital medical consultant, his co-writer Paul Benedetti, who recently – up until recently taught journalism at Western, who together are the authors of a book called Spin Doctors: The Chiropractic Industry Under Examination in Canada. That was from 2003. Most recently from a long-form article in the Globe and Mail in November 1st, 2018.

And we have an internal guest that some podcast listeners are well-acquainted with and that’s our colleague, Ned Pojskic, leader of pharmacy and health provider relations. Because today we’re going to talk a fair bit about the chiropractic community and health provider relations, and we wanted Ned in her to talk about what impact some of the findings of our writers and researchers here today may have on how we look at benefit plans in the future.

First, welcome to both of you.

[0:04:31.9] PB: Thank you.

[0:04:48.7] DW: You can tell these two have known each other for a while. I think that’s going to become clearer in the podcast. Paul, tell us a bit about your background and how you came to write this piece for the Globe and mail.

[0:05:00.4] PB: Sure. Well, that depends on how far back we want to go, David. As a journalist, I’ve been looking at what was called alternative medicine, and then later CAM, complementary and alternative medicine and then occasionally, holistic medicine for more than two decades, starting at the health and spectator and working with the southern chain of newspapers. I did special reports and some series investigating that world as it was emerging in the 90s really when it really began to pick up speed.

Through those years and across those years, I did work on dietetics, unregulated nutrition specialist and consultants, which was very big during the 90s and early 2000s. Holistic nutrition it was called in those days. Actually I did speaking tours for the Dieticians of Canada and was involved in some of that.

That led us into chiropractic, which even in those days was considered alternative to mainstream medical treatment. Wayne and I really embarked on our major investigative piece when I was at Canoe and Wayne was freelancing.

[0:06:00.5] WM: A failed internet enterprise. Right. Yeah.

[0:06:03.6] DW: I remember Canoe.

[0:06:04.5] PB: You remember Canoe? Yeah. Out of the sun media group, Canoe at its peak really was doing some neat things, and I was the executive producer of the health channel. Under the leadership of Mike Simpson, we were allowed to do really, and I’m going to state this for the record, what we think was the first direct to online investigative journalism in Canada. I think we can safely say that.

We launched a major series called Spin Doctors, which was looking at the relationship between chiropractic and mainstream medicine, at the time really set off by what Wayne and I discovered was a proposed partnership. You may not remember this, but it actually almost happened between the Canadian Memorial Chiropractic College in York University, to institute a degree program at York, resulting in a PhD in chiropractic.

We thought that was an amazing story. We dug into that story and that resulted in a larger story about the state of the industry. We followed that story with a second investigative series called Spin Doctors 2. So creative. I think Wayne can agree with that, which was on pediatric chiropractic, which was a specific hot button issue for the public after the first series.

[0:07:14.4] WM: What’s interesting about that was that we didn’t really know anything about pediatric, chiropractic until we did the first one. Paul said, it was direct online. We showed our homework, right? We had photographs of letters, we had audio clips, we had all those background stuff that we thought made sense for doing it online, because we had both worked doing future information products at Southern before we actually came to the Canoe and I was at AOL at that time.

What happened was in the discussion forums, which were fascinating and very perturbative and and most pretty funny in some cases. Anyway, the chiropractor started talking about treating kids and we’re saying, “What the hell?”

[0:07:59.8] PB: How successful they were at treating kids.

[0:08:01.1] WM: Yeah. We were like, “What? What, what ,what?” That was great for us, because it was a goldmine of all these people talking about this stuff that we didn’t know anything about. We went to town.

[0:08:11.4] PB: Yeah, that launched the second series. When Wayne says that, Wayne was a new media specialist and had actually pioneered a lot of the first online journalism in Canada. We really did show our homework. We had documents, transcripts, official document and  letters that we received from associations, audio and video which is new at the time, photo gallery.

It allowed people who were questioning us. We’d say, “Great. Don’t believe everything we say.” It was early on in media suspicion, but we let people go through the documents. In some ways, i thought the series was bullet proof. That’s why it led very nice to a book, because Wayne and I had done so much legwork that a lot of the book research was already in place.

[0:08:53.8] DW: Okay. That was back in the early 2000s, in 2003. What was the reaction to the book then and did it have any level of impact that you could see on what’s happened in the year since?

[0:09:05.9] PB: Well, that’s a tough question. Let me answer by saying that the impact to the series was pretty big, partially because the Sun Media chain picked it up and ran parts of it in print. That helped. The web was still somewhat nascent at the time. The print stories had a big impact.

We got tons of mail and we had a lot of accusatory letters and we did get several threatening letters. Interestingly, we never got sued. The reason we didn’t get sued was because the story was factual and bulletproof.

[0:09:34.9] WM: Yeah, absolutely.

[0:09:37.1] PB: You could be mad about it, but unless you can point to factual errors and/or any libel, which we of course didn't do, we didn't get into any trouble. In terms of impact, difficult to say Wayne, I'll throw it over to you.

[0:09:48.9] WM: We made dozens and dozens of dollars.

[0:09:52.0] DW: Congratulations.

[0:09:53.5] WM: I don't think it made any impact in the profession, apart from them having a target. Now we had targets on our back as the enemies of chiropractic. We can talk about that later, because it has an interesting influence on the current stories. I don't know that it made a significant difference in the profession.

[0:10:15.9] PB: I think it raised – I'll say this for sure, it raised the level of awareness among regular doctors who had a surprisingly low knowledge about chiropractic. In fact, most of the interviews we conducted was clear that we knew more about it than medical doctors did, including orthopods. You get that. Why should they know about it? They're busy enough with their own professions. I think there were red lights that went on at the Ministry of Health, but I think they went on and off. Yeah, not much really took place.

[0:10:43.7] DW: I ask that a bit, because we probably had our few moments of fame probably three or four years ago now with one of our GSC health studies, where we pulled out the data and we were shocked to see this, that children under 10 were a fast-growing user of chiropractic benefits. We married that with teenagers being a very growing population getting massaged. I'd said is that what benefit plans were intended to do? We made the Toronto Star, etc. Certainly had some challenging conversations with organizations from both sides. Obviously, these treatments continued. What led you in 2018, or was it even before 2018, to say we're going back to this place and talk about this again?

[0:11:29.6] WM: Yeah, let me just jump back for a moment about treating youth. One of the things that we did for the story about youth was we were worried a little bit about teens, because you can make a legitimate argument I think that teens get injured in baseball games and maybet even playing golf.

[0:11:43.6] DW: Yeah. We're a hockey nation and get to run into the board.

[0:11:46.5] WM: Yeah, hockey centric. When we did the story, we particularly focused on four and under. We did the stats. We ran the stuff for four and under and they were stunning. There was not too much argument about golf.

[0:11:57.8] DW: Yeah. This was colic and things like that, right?

[0:12:00.1] WM: Yeah. The numbers were really astonishing. I think maybe that's one of the points where the Ministry of Health actually did sit up in their chairs and when they looked at what was then covered and was being paid for sub two-year-olds. It when shocking. Anyway, to proceed.

Yeah, well I'll tell you what happened, a couple of years ago I got an e-mail and then a phone call from a young man named Ryan Armstrong who was living in London, Ontario and has a PhD in science and had stumbled upon chiropractic. Literally had stumbled upon it, seeing a brochure for a talk and then went to the talk. He's a guy with an investigative mind. Was completely stunned by the fact that in 2016 or 17, people were making these kinds of claims. Here's a guy who was totally immersed in science and evidence-based practice as a biomechanical – I think he’s had biomechanical PhD.

He came across us. Eventually he finds Spin Doctors if you look hard enough. He called me and said, “I'm thinking about doing a website and doing my own work as an activist on this. Can I interview you?” I said sure. That led to a correspondence and a bit of a friendship. What Ryan started to do, which we don't do as journalists, is he took an activist position and began because he was so upset, began sending in complaints, like actual written and fully documented complaints to the College of Chiropractic.

[0:13:20.5] PB: Kryptonite. I mean, in terms of chiropractic, they're so detailed and so good, right?

[0:13:26.8] WM: Yeah, they're amazing. They were the best kind of complaints I'd ever seen. He would footnote everything, document everything, right?

[0:13:34.0] DW: Research papers as complaints.

[0:13:35.9] PB: Yeah. We said to him, “Hey, Ryan. It's great talking to you. Can you send us as the complaints move through the system, can you keep us up to date?” We're really interested, because Wayne and I had tackled this very same thing many years ago for the book and we had seen complaints dead end. There's a chapter in the book called the complaints that went nowhere.

Well, as the results started to come in, Wayne and I started to talk again and we reignited our discussions about chiropractic, because the fate of the complaints was the same as it had been many years ago, that they would dead end. Ryan would then send his response to the complaint and then he actually took the step of appealing to the body that oversees the College of Chiropractic. I know this is a bit – that sued the HPARB.

[0:14:25.2] DW: Yes. That's the Health Professions Appeal and Review Board.

[0:14:27.9] WM: Thank you, David. Very helpful.

[0:14:31.0] PB: Yeah. I know that's a little bit arcane, but in fact there is a body that's supposed to watch the people that watch the professions. Ryan was diligent enough to then complain to them and we had all these documents.

[0:14:41.7] DW: This is a provincial government body, right?

[0:14:44.1] PB: We’re going to review this.

[0:14:44.8] WM: Yes. Then we went back and the original complaint that somebody would make about chiropractic, so you are harmed by a chiropractor, you think you got ripped off by a chiropractor, you would complain to the CCO. Those complaints, sometimes they're mentioned in the annual reports.

[0:15:00.8] DW: That's the national organization. No sorry, the college. Ontario College.

[0:15:05.3] WM: The Ontario College. Okay. You're complaining to the college. Sometimes those are mentioned in their annual report, sometimes in passing and sometimes in some detail, but the ones that get complained up to HPARB are online. We went back and we looked back 10 years of complaints and did a spreadsheet of what they were about and how they were resolved and stuff. We saw this really interesting pattern that if you look at complaints about billing practices, or sexual abuse, no problem. They're on it white on rice, right?

[0:15:38.8] PB: They handle them very well. I mean, I think we have to say that on financial issues on any impropriety, the college is quite diligent and we made that clear on our piece and I'd like to make it clear now. When there were issues around scope of practice or claims that were unscientific, they just skated through. What was really interesting for us was that when those complaints rolled up to HPARB, HPARB also looked at and said, “Well, those are scope of practice things. We don't have any say in that. That's the regulatory body, so okay with us.”

[0:16:14.6] WM: They would send them back down to the regulator.

[0:16:17.0] DW: Then you went on to describe what was happening at the regulator.

[0:16:20.3] PB: Yeah. When you're a self-regulating profession as you guys know, there's a huge responsibility that comes with the privilege of regulating your own profession. You don't have an outside policeman watching you. You are so respected that the government and all of Canada, all the patients in Canada, Ontario, trust that your members will watch out for the public within your own profession.

HPARB, because we have to clear this up, because HPARB sounds like it's a policeman above the college, but it isn't. It merely looks at process. It says, “Did you go through all the steps?” “Yes, we did.” This really interesting decision on scope of practice, that's your wheelhouse. We're just people who look at process. Wayne and I realized that that too was a strange dead-end in a process.

[0:17:09.5] WM: Yeah, and then factors – I don't want to get into it, because it gets really arcane, but it became clear that there's a couple of decisions that were approved by HPARB that now becomes canon law. That's not the right term for it, but they keep referring to back to this case and the present, and it was the Turner case that we mentioned in our stories, one of them, where it's about treating symptom, not the root cause. Again, it's arcane, but very important in terms of trying to understand how it is that you can have somebody in Ontario today who can treat a child for ADHD, ADT, autism by adjusting the immobile skull plates and be told by the CCO and HPARB thumbs up, good work.

[0:17:57.8] DW: Is that thumbs up, or is it just we're not even going to address this?

[0:18:01.9] WM: No, no, no.

[0:18:04.0] DW: They're actually condoning it, or just saying that's none of our business?

[0:18:07.2] PB: No, well from HPARB’s point of view, they're saying if the CTO says it's within scope of practice, okay. CCO is saying it's in scope of practice. They didn't sanction him. They didn't say stop doing it and this was a complaint that was made years ago and he's still doing it today and treating – he's doing what he calls a private research project on treating down syndrome, where he talks about changing eye shape.

[0:18:32.6] DW: Ned's in this room – we would pay for that, right?

[0:18:36.2] NP: Yeah, absolutely.

[0:18:37.6] DW: This whole system keeps going.

[0:18:40.3] WM: Yeah, and another point with the Turner case and it's a really important point in terms of what you pay for and stuff, is he's developed what's called the Turner method, which is this adjusting of skull plates that he just made up. He just made up. There's dozens of chiropractic techniques that chiropractors make up. The way D.D. Palmer made up the original, final subluxation adjustment stop, and you guys pay for those too.

Let's leave aside whether there's evidence for chiropractic in most cases. These are techniques that are piggybacked onto literally on top of chiropractic that practitioners just make up. Because they're chiropractors, like a CCO has said to Turner, “You just made this up on top of chiropractic, but it's in the scope of practice.”

[0:19:31.4] PB: What’s interesting about that is they're called name-brand methods. In the states, there's dozens and dozens and dozens of them. We won't bore you but there’s all kinds. They’re usually named after the inventor. In the case of Turner, an interesting subscript to that is he teaches it. He now proudly told us that he had inculcated hundreds, several hundred and maybe even a thousand other practitioners in his method, a completely unverified method of treatment that has no evidence to back it up other than his own anecdotal stories out of his own office.

This is the state of things that then doesn't get sanctioned. It actually gets a free ride and he has continued now for more than a decade. Turner has been operating at full throttle as he told us proudly. I mean, I'll say that Turner thinks he's doing good and he was proud of the work he's doing, but there's simply no oversight around stuff like that.

To make a longer story longer, that ignited our interest again. Armstrong's experience ignited our interest. What really ignited our interest and this tells you a little bit about Wayne and I, was the fact that rather than look into the complaints that Armstrong was making, the CCO looked into him and they began to monitor what he was doing. They looked at his website. They examined what he was doing and they published that material in their monthly report, so we could actually see that they were looking into him.

At that point I said, “Well, I think we've got something that's starting to look like a story.” We began to look into what the state of the situation was in Ontario now 2017. What we found, we put into the Globe and Mail story.

[0:21:10.7] DW: I encourage people to go online. You can find it very easily, the November 1st. It was a great Saturday morning read if I recall. The point being when you read that, it's clear that purveyor supporters of non-evidence-based practices have in fact been leaders of these purported regulatory bodies. To be fair, the impact of an article like yours clearly and you make mention of this, there is some level of a schism inside the chiropractic community. There are many people that are upset by these practices and I’m never sure by these practices, or by the fact that you're bringing them to light and putting a black cloud over the entire profession.

How would you characterize that rift that exists and is there a path, a logical path forward in that community to sort this out, so they don't have articles like this and they don't have carriers like us starting to put question marks around why are we paying for all of this stuff?

[0:22:08.4] WM: It's really complicated. It's complicated because I wish it was black and white, but it's not. For example, you have on the one end of – you got a look at it like the discussions about gender spectrum. There's evidence spectrum for chiropractic, right? That on the one end, you have the dyed-in-the-wool vitalists, the D.D. Palmer, innate energy flowing, God energy, healing, connecting with the universe. Those people exist and they're a strong voice within chiropractic.

Then there are people who seemed to be subluxation-based sort of that, that are believing that there are subluxation, believing that adjusting subluxation, they're removing the subluxation, which don't exist but they believe they do, can change the body's response to illness and can treat all manner of disease and disorder. Then there are chiropractors who are surely MSK, musculoskeletal who are pretty serious science-based folks and there's a proportion there.

Then there's another group that is a really interesting group that we call the Scully Mulder, X-Files view. That the Mulder of I want to believe, right? There's no evidence yet, but we think that there is evidence that's coming that will show that there was something that D.D. Palmer did that was efficacious to disease, but we don't have the evidence yet.

[0:23:43.0] DW: Just around the corner?

[0:23:44.4] WM: Just around the corner. There are chiropractors that when we first talk to them, we think yeah, these guys are evidence-based. Then you keep talking and it becomes clear that they're in this odd state of believe that in the future, there will be evidence that will bear –

[0:24:05.6] DW: We’ll all say we are right all along. When they say that, are there robust studies happening now that they're going to hang their hat on? It’s just wait till we get the research that comes out of this one? Or is it just something will happen somewhere that will prove this, but where are the dollars and the research?

[0:24:21.3] PB: Well, Wayne and I monitor the research really closely. I would add one other group to Wayne's spectrum. I think we should acknowledge this, that there are a number of people – it's not a huge number and you probably are familiar with some of them; people who start with a chiropractic degree after their undergraduate degree and go on to do postgraduate work, either in an MSC or a PhD. They go into epidemiology, or other areas. They're still DCs, but they've moved really pretty strongly into the area of science.

There's some of the strongest proponents of a move to evidence-based chiropractic, but there are not very many of them. I mean, you can count them on two hands, right? Anyway, that's the other group. We watch the studies very closely. Here's the problem, right? The gray zone is around widely treated areas that are difficult to assess, colic is a perfect one. It's a self-remitting problem. My son had colic when he was a kid, one of my sons and it starts mysteriously and one day and this is exactly how it goes David, one day you're holding your kid and you realize, he's not crying anymore. That's the greatest day, right?

It’s usually five weeks in, it disappears. Of course, they adjust. When it disappears, they take the credit, right? Asthma is another one, which was actually studied at McMaster in Hamilton. There are a couple of other otitis media, or commonly known as earache.

The results are no good. They're largely negative. The asthma study is negative, the otitis media is negative or gray and the colic one is just, it's really a question of coincidence more than anything, right? There's no mechanism of action that can be attributed to adjusting the spine. Nonetheless, many chiropractors say they're doing studies, or there have been studies and they say to the patient, there have been studies on this. Then they put a period there, they don't say there's been studies and the results are negative right?

The studies going forward are bizarre. Wayne and I find them all the time. They are largely case studies. I know you're not going to believe me, but please look them up. They're everything from hearing, adjusting and then testing a person's hearing after the adjustment, vision, doing a eye chart test, doing several back adjustments, doing a second eye chart test on a small cohort of patients.

These things get published there as Gord Guyatt would say, this is one of the lowest categories of evidence that the single case study, or even the multiple case study, they're largely very small. These things are used as ammunition, or evidence in this tension that Wayne's talking about in the profession. The top guys understand the levels of evidence and realize that these case studies are not entirely value less, but close. The other part of the profession finds this very reinforcing, that even if it isn't here just yet, these are bright signs on the horizon for the potential impact of chiropractic and human health.

[0:27:18.8] DW: Okay. There's hope out there.

[0:27:21.4] WM: Yes. Yes. Okay. Let me just turn to Ned for a second here listening to this conversation and certainly, Ned’s the PhD, know a little bit about research.

[0:27:30.1] PB: With science. Boy.

[0:27:34.6] DW: I'm surprised he didn't tell you before. He always let’s me –

[0:27:37.2] PB: Yeah, he told me that as I shook his hand. My only claim to fame.

[0:27:41.2] DW: Because we have undergone some work in this field and we're doing a lot of the research and we tend to have these dialogues with the paramedic community, not just chiropractic community where we hear, but we have evidence, but we have research, and what is your normal response to that

[0:27:56.2] WM: Yeah. The two things will often hear from the paramedical communities one, were self-regulated. We're regulated at these provinces and the conversation ends there, as if that is sufficient for payers to engage and pay for these treatments right? In a second conversation is yeah, there's evidence point to one study. Not a systematic review, not an overview of the literature, but it's one study. Yeah, I guess you alluded to this Paul, the argument is then therefore, there is something out there that should be good enough, let's go ahead and don't question whether you should be paying for it. I think that even more fundamentally, so if you look at this is ultimately a conversation about money, right? You follow the money, you understand the entire picture at the end of the day.

[0:28:35.6] DW: Explain what you mean by that.

[0:28:36.9] WM: If insurance pays for something, there's going to be a business model built around it, period. People getting coverage for things means that they can get coverage for something. It means that there's somebody out there paying for you, you're going to get treatment out there somewhere, right? Somebody's going to build a model around it. I think part of the challengs obviously is we need to reform our processes to better look at how we can pay only for evidence-based treatments.

[0:29:11.8] PB: We can speak that if you like, if you want to stop a little bit about what we think about that.

[0:29:15.5] DW: Yeah, sure.

[0:29:17.2] PB: We think that there is some evidence for the efficacy of SMT, which is spinal manipulation therapy.

[0:29:22.9] DW: We agree. We agree with that at some point.

[0:29:25.5] PB: Wayne and I are pretty sticky about this. That's not chiropractic. SMT is practiced by physiotherapists, various other people who do mobilization and some manipulation. I've gone to a physiotherapist who does mild manipulation and some mobilization, right? It's not purview of only chiropractors. There's some evidence that SMT can be helpful for the short-term relief of uncomplicated low back pain. That's not neurologically complicated back pain, right?

There's less evidence, even less evidence I would say for neck pain, but there's some. All of that evidence as far as I know and I looked at the latest Cochrane reports and so is Wayne, is within six to eight weeks and post that, there's little evidence of efficacy past that. Similarly with chronic pain, there are new studies emerging and Ned, I'd throw this to you, but still there's not strong evidence that chiropractic intervention is beneficial for chronic pain for MSK conditions.

What do you have? Well, I think legitimately and you can make a legitimate argument, that you have some evidence for intervention in those two areas in a short-term way for an uncomplicated problem. Gord guy would say, what's the quality of that Dr. Gordon guy, would say what's the quality of that evidence? Medium quality. Medium quality suffices in many areas of healthcare and we should be careful about that. Doctors do things with medium quality evidence, so do physios, so do manual therapists, all occupational therapists. We can't single out chiropractor for operating on medium quality evidence, but that's what it is. If we're wrong, let us know.

[0:31:00.6] NP: No, you're absolutely right. Medium level quality of evidence. You're right, in many cases of a healthcare system, we accept that as sufficient. Maybe in this case, we would as well. The problem obviously for the chiropractic profession is that's not a lot of business, right? You have to create chronic conditions. You have to have ongoing patients coming back, otherwise where is the business going to be?

That's what's for some of these other practices, some of these non-evidence-based practice; they expand the scope of practice, the number of patients walking in the door and ultimately, that means more business, right?

[0:31:30.7] PB: David, I wouldn't mind just jumping on the point of the expanded scope of practice. Wayne, explain how neurology and chiropractic connect to make the business bigger?

[0:31:39.3] WM: Well, there's a real sense that some chiropractors feel that there is a neurological benefit from chiropractic adjustment that is not simply MSK. That opens the door to all kinds of treatment, because as soon as you root that door open, then you're back to D.D. Palmer, then you're back to the idea that there is this relationship between spinal adjustment and visceral disorders. That gives license to a scope of practice that is almost all encompassing.

We've seen this with the most recent story we did for The Globe and Mail, there's a chiropractor named Dr. Nantais who was complained about for offering cancer prevention clinics. The complaint was taken to the CCO, the CCO looked at it and the CCO said that's within scope, right? That either maybe some efficacy for chiropractic adjustment in improving the immune system, so that would help prevent cancer and build the body strength up. That is a great example of when you open the door to this neurological engagement of chiropractic adjustment and the removal of subluxation, increasing nerve flow and an innate energy through the nerves, then you allow just about anything. That's not a theoretical on our part. The Nantais document, the Nantais judgement, it was on a silver platter handed to the CCO, here's a case where this has gone bad. The CCO said, “No, it hasn't. It's within scope.”

[0:33:12.9] PB: The reason that spurred the story and got the interest of The Globe and Mail is I think everyone in Canada would agree that a red line is cancer. It's the red line, right? If you're a purveyor of false remedies for cancer, you are not liked by anyone. You're a bad person, right? We figured the red line was right there for the CCO to say to Nantais, “No, you can't even say it may help. It's just too far. We don't have any evidence that chiropractic can in any way affect the course of cancer, whether to prevent, treat, or prevent future cancer, right?”

They chose to say yes. That wording is crystal clear and it's in the story. They allowed Nantais to continue giving the sessions by adding the word may prevent. Well, as Wayne just pointed out, you can say that about everything, everything, which opened the door even wider for the treatment of all disease.

[0:34:05.6] WM: Just to put an interesting twist on that, that in our book, it was interesting going back, Nantais comes up in our book and he was complained about by it back then by a doctor for making claims about treating eczema and ADA, a variety of disorders. In the course of the complaint back then, which is in 2001 or 2, he says to the CCO, “What if I put may in my claims?” They say okay. He's done this before.

[0:34:38.5] NP: There's a fundamental problem I think underlying all of this in our regulatory system, right? In Ontario at least, we have a regulatory system that is called the controlled acts model that eventually says different health professions can do different things. A dental hygienist can scale teeth, a dentist can do root canals, etc. For chiropractors, it's spinal manipulation. Nowhere in that regulatory framework do we talk about what does spinal manipulation actually treat? This is what the door that opens up in a regulatory framework to say you haven't specifically forbidden it, so you can make any claim you want.

Now how do you regulate that? How do you start to assign specific conditions to specific controlled acts? That's almost the next layer, right? The way we do with drugs. We have specific drugs can only treat the following and we stipulate and prescribe that. If you say anything outside of that, you're off scope. There's that model that we could replicate.

[0:35:29.6] DW: Those drugs when they come to us for assessment, come with a binder full of scientific evidence. Let's face it, we're in this room often highly critical, a big pharma and usually around the cost of these drugs, but we always have to give it to them. They come with something to explain why it exists and what good it will do. This is where it gets a little bit hazy for us.

[0:35:52.5] WM: I think the controlled act is really interesting. It just actually came up in a really interesting CCO meeting, public meeting on November 29th that Paul and I were at, which was fascinating, where the issue of the neurological engagement came up of whether or not chiropractic adjustment actually has an impact on the nerves of the body. You want to talk a bit about the Doctor Budgell?

[0:36:16.8] PB: Yeah. They were veering really close to the problem, what the issue was. The argument around – this is so interesting, because it cuts right to the heart of the matter, right? Chiropractors may and can adjust the spine. That's what they do. The issue is as Ned pointed out, what are they doing when they're adjusting the spine, right?

The CCO is very clear with us and has been in their response to the Globe and Mail, that as long as chiropractors adhere to the rules and regulation of the act that allows them to be chiropractors, they may practice. That’s what they say, right? Now the question that's the big elephant in the room is and it was mentioned by Dr. Budgell, the CMCC professor, what is the scope of practice? I have to say the room went silent when he said that and we recorded it, so we have it. There's the key. Yes, of course they can use MSK, do adjustments, look at the patient. What are they treating?

[0:37:12.0] DW: Well, the reality exists on their websites as you've described it, right? That's the world we're in now. That is the real scope of practice.

[0:37:20.4] PB: Yeah, not everyone. Wayne and I have a collection of online ads that fill file folders, electronic file folders of treating everything from bad wedding to infertility, to erectile dysfunction, to high blood pressure to, I don't know name it Wayne.

[0:37:36.1] WM: All sorts of childhood disorders. We've come across more than one instance of chiropractors basically sneaking into hospitals to treat newborns, right? Which you guys are paying for, right?

[0:37:48.2] PB: We did verify that incident and we do have that. It didn't get into the story because it's too complicated, but there have been instances where parents have asked the chiropractor to come in, who then gives treatment inappropriately because they don't have rights to operate within a hospital.

[0:38:04.2] WM: We heard a story recently about a chiropractor coming into hospital and locking an elevator and treating the patient in an elevator in a hospital that didn’t have – it’s fascinating.

[0:38:15.4] PB: These are again, we don't know the proportion of chiropractors are engaged in this very, very wide scope of practice, David. I mean, that's the big question. We have a sense that some of the associations must know as they've done surveys and would have a way better knowledge of what the profession looks like. We can only intuitive from various studies that have been done and published. We have some numbers around that. We also have some fairly strong numbers that are recent on vaccination and the attitudes towards vaccination, which are very revealing of the greater mindset. We know about that.

If you’re anti-vacs, it means that you believe in innate energy that protects children against diseases, instead of vaccines, right? It's a complicated playing field, particularly for you guys because it's hard to know what you're paying for and who you're paying.

[0:39:02.9] WM: The other piece of this is that when we talk about the self-regulation, we're basically talking about to some degree the failure of self-regulation, right? There are mechanisms to fix that that have been invoked in the past. For example, we have legislation that allows the Ontario Minister of Health to step in and take over a regulatory college by appointing a supervisor. That has happened in the past, for example for petitions, where it simply said, this is not functioning, right? We haven't seen that yet in this regard and maybe that's a potential next step.

[0:39:28.9] DW: Yeah, because I was going to try to bring this to a close and say we can go all night.

[0:39:34.3] WM: I know we can too, but where do we go from here? What is a reasonable path forward to make sure patients have a better level of care that this is not as prevalent as it is?

[0:39:47.4] PB: I think it's really difficult for the profession itself, because if you go online, you can't swing a dead cat without hitting some ridiculous claim about chiropractic, that we don't know the percentage of chiropractors who are operating in the unscientific zone of chiropractic, but it seems judging from online experience, there's a lot of them.

I think that the profession has shown itself in Ontario anyway, really incapable of regulating that, because they've had decades to do it and they just don't seem to be able to do it. There needs to be some outside intervention, I think, right?

[0:40:28.3] DW: Even if we change the board though, even if the vitalists were taken off the board and we had all of the more, let me call it mainstream chiropractic voices, this would even they go to these corners of the community and drive them out, or its self-regulation even in that case where you've got these are smart responsible people, but self-regulation just doesn't lead to the cleansing of the corners of the profession.

[0:40:53.6] PB: Well, let's be clear about two things, right? We wrote the book published in 2002 and the situation in 2017 is worse. Vitalists control the CCO executive and that's proven in our story. We haven't been challenged on that. There's no way in the short term that that can be altered. For the next step and I think you asked a great question, what's the next step? I'm going to throw it to a voice of in chiropractic, which was one of the scientific chiropractors holding a PhD in operating out of U of T who said, “We shouldn't be self-regulated. We should be regulated by the government. We should continue to be a regulated health profession.” He was clear about that. There's too much self-interest among chiropractors to regulate themselves.

Wayne and I think that would be a good first step, but I tend to think that the situation we're in now and I'm only speaking for myself, this is a judgment call, I think what Ned suggested is correct. I think that it's time that an outside person from the government, the Ministry of Health stepped in as a supervisor and took self-regulation away from the current board and reevaluated the situation. I think scientist and activist Tim Caulfield said the same thing, that it's time that an outside body came in using what he calls a universal scientific standard and try to bring the house in order. I think scientific chiropractors would welcome such a change.

[0:42:16.8] DW: Yeah. Is there any indication that the government is interested in doing that?

[0:42:20.9] WM: We'll find out I think when the house gets back together, the Queen's Park comes together in on February 19th, I think. Whether that gets raised in the house by the NDP health critic, if there's a call for it, we don't know that's going to happen, but it seems that might be a natural next step. If there isn't between now and when the house sits, the Queen's Park sits, that there isn't a significant change, maybe that will take place, right?

We don't see with advocacy groups like the Ontario Chiropractic Association has had ample opportunity to speak out against unscientific practices and they haven't done a very good job of that. They've said clean up your act, get the stuff off your websites and stuff, but that doesn't address practice. That just addresses the –

[0:43:06.0] DW: PR component of this.

[0:43:07.4] WM: The PR component.

[0:43:08.3] DW: Us sitting in this room talking about it.

[0:43:10.1] PB: Before we sign off and thanks very much for this opportunity, it's been a lot of fun, it’s been interesting too, I just want to come back to one really important thing. You guys are in the business of helping people by being insurance providers and trying to provide the best insurance from an – I’m just very happy to hear that you're a not-for-profit insurance company, which is really fabulous. That's where we come from. We have no stake in this. We've done all kinds of topics on all kinds of stories. I've written all kinds of things and so as Wayne.

What we worry about is the public. I think that we need to come right back at the end of this discussion to the patient, right? The profession is the profession. They need to deal with themselves and get cleaned up. What is happening to Canadians every single day? Today, yesterday and tomorrow while this goes on? We think it's an appalling situation that people are going in and getting treatments that are not efficacious. They're paying for them often out of their own pocket, or through your services for treatments, for things that don't exist, subluxations, or for treatments that don't do anything. That has to end. It's wrong. We don't make any claims about safety. Overall, I think chiropractic is a relatively safe kind of practice.

[0:44:17.5] WM: Maybe neck adjustment is an issue.

[0:44:19.3] PB: Neck adjustment aside, that's a different issue for another podcast. Adverse reports are not done very well in the profession, so we don't know what the evidence is there. I think overall, we can say not that many people are being harmed in a physical sense, but pocket books and the psychology of parents who think their kids are sick with subluxations, these are terrible things that need to be cleaned up.

[0:44:41.9] DW: Okay. I'm going to end there. Thank you so much for spending this time with us.

[0:44:44.5] WM: No problem.

[0:44:45.1] DW: I hope we talk again in the future.

[0:44:47.3] PB: Yes. Thank you.

[0:44:47.5] DW: Thank you.

[0:44:48.4] WM: Thanks.

[END OF INTERVIEW]

[0:44:52.8] SM: Thank you to our listeners for tuning into another episode of And Now For Something Completely Indifferent, a Canadian health benefits industry podcast. To be sure to get future episodes, please subscribe to this podcast wherever you get your podcast or visit our website at greenshield.ca/podcast to download. As a reminder, we talk about these issues consistently in our publications, which are available on our website as well as on social media. So be sure to follow the conversation. For this specific episode, you can check out our September issue of the Inside Story.

Thanks for listening and we’ll talk again soon.

[END]