1. The Ethical Puzzle of Chiropractic Stephen M. Perle, D.C., M.S. Associate Professor of Clinical Sciences University of Bridgeport College of Chiropractic

2. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Three Descriptive Ethics Observations of Some DCs Quomodocunquize Ultracrepidarian Boundary Violators

3. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved To Quomodocunquize The desire to do anything for money

4. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved What causes DCs to Quomodocunquize High education related debt Poor reimbursement

5. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Decreasing Market Share Feuerstein M, Marcus SC, Huang GD. National trends in nonoperative care for nonspecific back pain. Spine J 2004;4(1):56-63. 40.48% 30.63%

6. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Cost of Chiropractic Care At one time less expensive than medical care May be more expensive now Stano M, Haas M, Goldberg B, Traub PM, Nyiendo J. Chiropractic and medical care costs of low back care: Results from a practice-based observational study. Am J Manag Care 2002;8(9):802-9.

7. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Health Care Economics As supply increases costs increase Due to “physician-induced” demand Fuchs VR. The supply of surgeons and the demand for operations. J Hum Resour 1978;13 Suppl:35-56. Overpopulation of DCs Increased need for $/patient Higher office fees Higher PVA MCOs make this hard – W/C or PI or cash

8. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved What causes DCs to Quomodocunquize Ethical blind spots & poor ethical decision skills PI Mills “teaching” new DCs fraud Affluenza

9. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Af-flu-en-za (n): The bloated, sluggish and unfulfilled feeling that results from efforts to keep up with the Joneses. An epidemic of stress, overwork, waste and indebtedness caused by dogged pursuit of the American Dream. An unsustainable addiction to economic growth.

10. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Ultracrepidarian Claiming Expertise One Does Not Possess

11. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved What Causes DCs to Be Ultracrepidarians Natural tendency Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one's own incompetence lead to inflated self- assessments. J Pers Sociol Psychol 1999;77(6):1121-34. Large egos and small self-esteem Can’t say I don’t know

12. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved What Causes DCs to Be Ultracrepidarians Poorly developed C.R.A.P. (Convoluted Reasoning or Antiintellectual Pomposity) detectors Chiropractic education that did not teach Critical thinking Clinical uncertainty is normal

13. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved What Causes DCs to Be Ultracrepidarians Byproduct of the AMA boycott We had to do it all – not now though Doctors who proselytize their pseudo- or anti-scientific “techniques” “Know where, when, how and why to adjust” “Practice with certainty”

14. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Chiropractor pleads guilty to fraud On taped call, she advised against drugs for epileptic By Pete Shellem - July 03, 2003 A taped phone call in which a Luzerne County chiropractor assured a woman that a dying epileptic would be all right without anti-seizure medication led to a guilty plea to fraud yesterday in U.S. Middle District Court. Joanne M. Gallagher, 43, of Hazleton, pleaded guilty to a single count of mail fraud which carries a maximum term of five years in prison. … Strohecker died after suffering massive seizures while under the care of Gallagher, who claimed she could treat epilepsy and Down syndrome through chiropractic... Gallagher assured Schade that the seizures and vomiting were a result of Strohecker's purging her system of medication…. "Eventually you will see her just go into a peaceful sleep," Gallagher told Schade, according to a transcript of the taped conversation. "And it's going to take her brain a little while, she's going to be tired for a while, but she'll recover.“ Schade found Strohecker dead the next morning….

15. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Ultracrepidarians Violate Ethical Duties Credat Emptor – let the buyer have faith Hughes EC. Professions. Daedalus 1963;92(Fall):655-68. Fidelity – duty to comply with patient’s reasonable requests Patient’s expect us to acknowledge our limitations Patient’s expect us to be up-to-date Belief in truth is not enough

16. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Boundary Violations See Dr. Foreman’s presentation

17. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Organizational Changes Protect the Integrity of the Brand’s Image –The Brand Is Chiropractic Publicly denounce unethical, unscientific practices and those who practice them Make sure all publications and web sites present scientifically valid info Grod JP, Sikorski D, Keating JC, Jr. Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies. J Manipulative Physiol Ther 2001;24(8):514-9.

18. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Organizational Changes Vigorously support public health measures Healthy People 2010 Vaccinations

19. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Educational Changes Increase enrollment standards Purpose Decrease enrollment in our colleges Help attain cultural authority Teach ethical problem solving skills Vigorously support public health measures Need to stimulate the chiropractic professorate to become scholars

20. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Educational Changes Make sure all publications and web sites present scientifically valid info Sikorski D, Grod JP. Unsubstantiated web site claims of chiropractic colleges in Canada and the United States. J Chiropr Ed 2003;17(2):113-19. Hospital rotations/clerkships Post graduation education Rigorous residencies e.g. DACBR Ensure continuing ed presents valid info Ensure those teaching CEs are qualified Specialization is NOT board certification from every board

21. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Educational Changes End credulity, empiricism, anti- intellectualism and devaluing research Stimulate critical thinking skills in students and the profession at large. Stimulate a love of knowledge i.e. real philosophy Make research part of everyday chiropractic - journal clubs.

22. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Philosophy Stimulate a love of knowledge i.e. real philosophy Lose the dogma Lose anti medicine attitude Lose anti science attitude Lose anti intellectual attitude

23. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Other changes Develop and maintain up-to-date best practices database Stop eating our young Create support systems for new graduates to keep them out of the practices that train them for fraud

24. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Oversight Changes Not everything a chiropractor might do should he/she do Jim Parker was wrong! Every technique does not work! Keep an open mind but not so open your brains fall out Vigorous enforcement action against unethical, unscientific, unqualified, or ultracrepidarian practitioners Never forget a profession is supposed to be self- regulating Ensure continuing ed presents valid info Ensure those teaching CEs are qualified

25. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Be Proactive – Enforcement Enforce current laws Diagnosis isn’t a crime, not diagnosing is Fraud steals the professions reputation Standards of care – not dictated by the doctor’s needs but by the patient’s Search the web & media – they aren’t hiding Inform public how and where to complain Inform the profession how and where to complain

26. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Be Proactive – Continuing Education Critical thinking Evidence based practice Ethics Don’t be an ultracrepidarian – know your limits Don’t quomodocunquize – fraud kills chiropractic Boundary issues

27. “The work of an intellectual is not to mold the political will of others; it is, through the analyses that he does in his own field, to re-examine evidence and assumptions, to shake up habitual ways of working and thinking.” Michel Foucault French historian and philosopher

28. (c) 2004 Stephen M. Perle, DC, MS All Rights Reserved Don’t let Kimberly Lee Strohecker die in vain

29. “Be ashamed to die until you have achieved some victory for humanity.” Horace Mann