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Chiropractors vs. AMA

Thanks to an important legal victory and changing attitudes among young MDs, chiropractors are beginning to get some respect--but old ideas die hard.



"The AMA has built a fortress around medical care in this country. They have achieved their fortress illegally. They're in the position of power in the health-care system."

So says Chicago attorney George P. McAndrews, who represented a group of chiropractors in an antitrust suit against the American Medical Association, Wilk v. AMA. Among those who agree with him are former District Court Judge Susan Getzendanner, the U.S. Court of Appeals for the Seventh Circuit, and the U.S. Supreme Court, which in November 1990 upheld Getzendanner's 1987 finding that the AMA had for years engaged in an illegal boycott of the chiropractic profession when it forbade physicians, in its code of ethics, to associate professionally with chiropractors.

"The important thing is that the lower court found that the AMA's motivation was predominantly patient care and a concern for patients," says Kirk Johnson, general counsel for the Chicago-based AMA. "That makes the case unusual--it's an antitrust case where the principal concern was not economic."

The AMA officially changed its ethical statement in 1980--four years after the first suit was brought against it, though the AMA began making small alterations to its policies shortly after that 1976 suit. But critics charge that the attitudes behind the original policy remain largely in force today. And with good reason, some medical doctors maintain: chiropractic, they say, is a cult, with no scientific evidence to back it up.

That attitude has hurt chiropractors in the past and continues to hurt them today, say members of the profession. Both sides claim their primary concern is the well-being of patients, patients who might be helped--or hurt--by chiropractors.

Chiropractic--from the Greek cheir and praktikos, meaning "done by hand"--has come a long way since its beginnings late in the last century. Although its proponents claim antecedents for spinal manipulation going back to Hippocrates himself (460-377 BC) and cite mentions of "massage procedures" in the Bible, chiropractic itself was founded by Dr. Daniel David Palmer in 1895. He based his work on the theory that "subluxations"--stiffness and tightness of the vertebrae--caused virtually all physical ills, and that manipulation of the spine, using a series of short, sharp shocks, was the cure.

In 1924 the archetypal curmudgeon H.L. Mencken termed chiropractic "this preposterous quackery," explaining it as a "pathology grounded upon the doctrine that all human ills are caused by the pressure of misplaced vertebrae upon the nerves which come out of the spinal cord--in other words, that every disease is the result of a pinch. This, plainly enough, is buncombe. The chiropractic therapeutics rest upon the doctrine that the way to get rid of such pinches is to climb upon a table and submit to an heroic pummeling by a retired piano mover. This, obviously, is buncombe doubly damned." "Buncombe" still sums up the views of many medical doctors on the subject.

But chiropractic's not like that anymore, according to chiropractor James F. Winterstein, president of the National College of Chiropractic in Lombard. "When chiropractic started, it had a pretty dogmatic approach--but it's changed. I went to school in the 60s, and I was not taught the one cause/one cure theory. I wasn't taught not to believe in germ theory.

"At the turn of the century, medicine was in a pretty bad array. Give us our due for correcting our early faults! Certainly, what we teach our students here is standard medical science; we simply choose to take a drugless approach. It's not that drugs aren't necessary--but they're often overused. Lots of medical doctors are emphasizing nutrition and exercise today; well, we've emphasized nutrition and exercise for decades. And the whole concept of physical therapy was pioneered here at National College in 1910."

According to Winterstein, even D.D. Palmer realized there were other factors than spinal problems in disease. "It was his son, B.J. Palmer, who placed chiropractic in a quasi-cultist approach, with a lot of talk about the 'power that heals in the universe.' It's an interesting concept, but it's not supported by any good scientific evidence."

At National College of Chiropractic, the nation's second-oldest school of chiropractic (after Palmer College, in Davenport, Iowa), "We have never denied germ theory," says Winterstein. "We have never stated that biomechanical spinal disrelationships [subluxations] were a single cause of disease. Our students get the same education that a medical doctor does, except in materia medica [drugs] and surgery."

One orthopedic surgeon who agrees--cautiously--that chiropractic can be useful is Oak Park's Boone Brackett. "I certainly agree that chiropractic has a place. There have been cases I just haven't been able to help; if that patient asks me about chiropractic, I'll say, 'Give it a try.' A number of them have been made better. I don't understand it--there are no reproducible results, and I don't see how the scientific method is applied--but empirically it seems to work. I think there are good chiropractors who know how to help people. Part of that is knowing when you can't help people, and sending them to a medical doctor."

Brackett describes himself as a conservative. "Anyone who does surgery realizes the risk--that surgery should be the last resort if anything else might do the job. Chiropractors are there to try to help and alleviate problems, and so are we, and whoever can do it best, should. I've always felt that way."

"The AMA is always saying that to go to a chiropractor may mean a delay in getting proper medical care. I submit that to delay proper chiropractic care is also malpractice." Chester A. Wilk is a feisty chiropractor (some might call him a loose cannon) from Park Ridge who has turned his loathing of the American Medical Association into a lifelong cause. The author and publisher of a 1973 paperback, Chiropractic Speaks Out: A Reply to Medical Propaganda, Bigotry and Ignorance, Wilk and three other chiropractors--James W. Bryden, Patricia B. Arthur, and Michael D. Pedigo--brought the case against the AMA that came to bear only Wilk's name in 1976.

Wilk says that in the mid-70s he received internal AMA documents from a source he calls "Sore Throat"--documents that showed the determination of the AMA and its Committee on Quackery to, as they phrased it, "contain and eliminate chiropractic," using legislative and other means.

"They're not dumb--they're evil," says Wilk heatedly of the AMA and their view of chiropractic. "They talked about the 'chiropractic problem,' and "containment and elimination' of the whole chiropractic profession. They put it in writing--thank God they're doctors, not lawyers, or we wouldn't have had all that proof. The AMA used propaganda smears and the big lie against chiropractic."

For decades, the AMA's aim went unchallenged. "Fundamentally, it's an outrage that the legal system had to come in and tame the AMA," says McAndrews, whose brother teaches at National College. "This is the third time it has been found guilty of violating the nation's antitrust laws." In 1941, the AMA lost a case in which it tried to stomp an early HMO; in 1982, the courts forced it to allow advertising and contract employment of MDs. "In 1987, Susan Getzendanner found the AMA guilty of decades of lawless behavior--and 'lawless' is her word," says McAndrews. "It wouldn't be so offensive if it were a less powerful group. But the AMA is a health-care bully. Historically, it has attempted to wipe out every competing health-care provider--podiatrists, doctors of osteopathy, optometrists, and anyone else that competed with its members."

"The chiropractors are using this decision as major PR," Johnson responds. "In fact, we spent a lot of money on ancient history in this case. Actually, it wasn't the AMA's ethical rule that made physicians not want to associate with chiropractors. Their training, their background, their understanding of the human body is just different.

"There is no scientific basis for chiropractic. That subluxations of the spine cause disease is the founding tenet of chiropractic. The physicians felt strongly about it. You might find some physicians who find the physical-therapy aspects [of chiropractic] useful--but you won't find any who agree with the scientific basis."

Actually, it's difficult to find MDs, particularly among the ranks of orthopedists, who will talk about chiropractic at all. James Ahstrom, head of orthopedics at West Suburban Hospital Medical Center in Oak Park, wouldn't comment on Wilk--but he did note that he does not make referrals to chiropractors. "A chiropractor gives physical therapy, and if I want a patient to have that, I send him to a physical therapist. That way I have some control over the treatment, and some kind of communication; I write the orders [for treatment].

"Some chiropractors send me patients, and some of those chiropractors are pretty smart. But their fundamental philosophy is not very scientific. They stretch the joints, crack them a little bit, and make you feel better. The danger is, a person with a real problem may get worse. Sciatica is usually caused by a ruptured disc--and to manipulate with abandon is probably not the best thing for it."

Per Freitag is an orthopedic surgeon who testified in the Wilk case--on the side of the chiropractors. He lectures to chiropractic students regularly, and has worked often with chiropractors. "My colleagues are basing their views on ignorance and rubbish," he proclaims. "Most chiropractors nowadays are very well trained. When it comes to anatomy, I find chiropractic students much more meticulous and careful than the medical students at the University of Illinois--medical students have to take too many shortcuts to cram everything into four years. I find chiropractic a very useful adjunct in the treatment of patients with back problems.

"Perhaps it is just because I am a stubborn Norwegian, but I prefer conservative, nonsurgical treatments of back problems. I send my patients to physical therapists or to chiropractors; I give them a choice--of course, not everyone responds to the same thing. If a patient has not tried any manipulative-type therapy, I have them try it, among other things."

Sciatica, he notes, is "self-limiting. It's not like a tumor that has to be operated on--most people get better eventually. So I prefer nonoperative treatments. Chiropractic manipulation gets patients pain-free faster than medication alone or bed rest with medication--and who likes to be in pain?"

Freitag remarks that he has treated patients with similar problems at two hospitals, Lutheran General and John F. Kennedy. "I treated them the same, with physical therapy, medicines, bed rest, and traction. JFK had chiropractors on staff. And those patients who were manipulated got better in half the time, combining chiropractic with medical treatment.

"Like most doctors, I always assumed that everybody wanted to be an MD. Then I started getting to know some chiropractors--and I found that some super-bright guys who could have gone to any medical school in the country really wanted to be chiropractors."

"I don't engage in name-calling, but there are a lot of problems with chiropractors," says Stephen Barrett, of Allentown, Pennsylvania, a psychiatrist and editor of a nutritional newsletter whose avocation is exposing what he sees as the evils of chiropractic. "A large percentage of chiropractors have people come in once a week, or once a month, for life to have their spines adjusted. I don't think that's legitimate. They engage in illegal activities with vitamins, which they prescribe for diseases--and they make a lot of money on those vitamins. They have some very strange treatment practices. A fairly sizable number of chiropractors are doing these things, and the evidence of it is the ads in their journals. There wouldn't be all those ads for vitamins in chiropractic journals if the chiropractors weren't buying them! People say, 'There are a few rotten apples in the barrel'--well, I count the barrel differently. I'm not talking about 5 percent of chiropractors, I'm talking about 25 percent--maybe even 90 percent."

While Barrett says that manipulation is "a valid medical technique," he's not willing to say the same for chiropractic. "Chiropractors define subluxations in any way that suits them. They claim a whole range of disease is caused by subluxations. Chiropractic leaders claim they gave up that theory--but they haven't."

Why haven't these accusations been made elsewhere? Barrett thinks the news media is on the side of the chiropractors: "There has not been a single article in the national press critical of chiropractic since 1975. There have been almost no efforts by the media to do real investigations."

As for the Wilk case, "Basically, that didn't change very much," he says. "Chiropractors say the AMA used to pressure doctors not to associate with them. In fact, doctors felt very little pressure from the AMA. They had a low opinion of chiropractors, and they didn't want to have much to do with them.

"If every patient took the most intelligent path to deciding [whether or not to see a chiropractor], I'm not sure chiropractic would survive."

Confronted with Barrett's claims, Winterstein sighs: "Stephen Barrett keeps saying the same things over and over, no matter how often we correct him. A lot of his accusations date from the 1960s."

The laws of Illinois and of most other states, Winterstein points out, permit chiropractic physicians to prescribe food supplements and change diets. "Barrett feels supplements are totally unnecessary--a position many orthodox medical physicians have taken in the past." He adds that many doctors have also, in the past, denied that eating certain foods might make one more or less susceptible to cancer--a view that has been altered by recent orthodox medical research. "The fact of the matter is that chiropractic as a profession has been teaching nutrition since 1910--while the medical profession has ignored it."

What about those "lifetime care" spinal adjustments? Winterstein responds: "I liken that to the medical practitioner who says to his patient with diabetes, 'Come in every month and let me check your blood sugar level, so I can see if you need to be on insulin for the rest of your life.' A lot of cardiologists are now recommending that their patients take aspirin once a day, every day, for life. There's been anecdotal evidence for decades that people who get their spines adjusted regularly feel better. Now there's immunological research showing that adjustment of the spine causes increased activity of the white blood cells."

A study published in the June 2, 1990, issue of the British Medical Journal, "Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment," reported that "chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain. . . . For patients with low back pain in whom manipulation is not contraindicated chiropractic almost certainly confers worthwhile, long term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain. Introducing chiropractic into [National Health Service] practice should be considered."

The same study also found that chiropractic treatment has economic benefits: fewer treatments were needed than in conventional medical care, and fewer sick days were taken by patients treated by chiropractors. "There is, therefore, economic support for use of chiropractic in low back pain, though the obvious clinical improvement in pain and disability attributable to chiropractic treatment is in itself an adequate reason for considering the use of chiropractic."

"My dad was a chiropractor, and he went to jail, because the medics would have him arrested for practicing medicine without a license," says chiropractor James Cox. "Now I lecture to MDs who get their licenses renewed for listening to me. Isn't that a turnaround?"

Cox, from Fort Wayne, Indiana, is a nationally recognized expert in lower back pain who has developed a technique for the manipulation of patients while they're in traction. "Back surgery used to be used a lot, as a cure-all for disc protrusions. But now, using these techniques, 95 percent of cases can be reduced without surgery." His biggest contribution, he says, is a textbook, Low Back Pain: Mechanisms, Diagnosis, and Treatment--a textbook with contributions from MDs. "I don't seem to have a lot of problems with interdisciplinary work [with individuals]--none of this Dark Ages stuff."

At the same time, Cox is still confronted with the medical establishment's hostile attitudes. "We have many scientific studies that show these techniques are effective, but some MDs still say that chiropractic is not scientific. They've said that for 100 years, and nothing will ever stop them. Chiropractors now have the same training, except for surgery and materia medica. We take the same tests. But there's no way that chiropractors can ever do enough to win the approval of the AMA."

River Forest chiropractor Cheryl Haugh says in regard to the Wilk decision, "I have not personally seen any major changes. I think prejudices and attitudes exist on a one-to-one basis, and I think that's how they have to be changed.

"I've got generally good relationships with local MDs. But one local orthopedic surgeon's office refused to let me examine a patient's X rays: 'You're a chiropractor, and you people never return them.' Sure, they take patients when I send them to them--who's going to turn down a referral? That's not an issue; working relationships is the problem. If I refer people, I want a report of [the doctor's later] findings and that person's records. For the most part that happens--but I still get refused often enough for it to hurt."

Haugh points out that the state of Illinois licenses all chiropractors as primary-care physicians--"meaning that people can come here and feel confident that they will have their medical problems taken care of, or that they'll be referred to the appropriate person. I was given adequate hours of class and clinical time to evaluate problems, and to make an accurate diagnosis. The state licenses me to order diagnostic procedures--X rays, CAT scans, blood work, EKGs, EMGs."

Most chiropractors consider more than just the skeleto-muscular system. We can help with problems with headaches, sinuses, digestive trouble--although that's not to imply that this is a cure for cancer! But with things like nutritional intervention, I'm trying to make sure that people are using all the resources available to them--that they're eating right, resting when they need to, exercising, that they're aware of addictive substances they might be overindulging in, that they are involved in stress reduction."

Like other people who favor chiropractic generally, Haugh points out that, yes, there are bad chiropractors--just as there are bad MDs loose and treating patients. "I feel that, like the victim of any other prejudice, I've got to work twice as hard to show my qualifications. It certainly takes more energy."

The negative attitudes of the medical establishment persist despite Wilk. Haugh says that several of her patients have been told by their MDs that they won't treat them anymore if they continue to see a chiropractor--that it's still happening, well after the judicial ruling. "I've seen the results of this attitude, and it costs the patients, in terms of their pain and loss of mobility. Yes, the issue is my business, and that's one side of it--but the issue is also, ultimately, the patient. And the issue is also letting patients make their own informed decisions."

"I'm not as adamant against them as a lot of the other docs are," says Elliott Kroger, an internist affiliated with West Suburban Medical Center and Rush-Presbyterian. "I see them as high-class physical therapists. That may seem condescending, but I think it's an important role.

"They didn't teach us about chiropractors in medical school; it's like they were nonpersons. But the attitude is really not as hostile as the Wilk case suggests--it's more like a kind of benign neglect. I don't think we got any information [about chiropractic], except some casual information about what their philosophy is.

"I do think the hostility has lessened over the years; the younger docs are more open to things like chiropractic and acupuncture. I would include chiropractic in a nonpharmaceutical approach to certain chronic musculo-skeletal pain syndromes.

"Some of my patients with low back pain come in and tell me after the fact, sheepishly, that they saw a chiropractor; they expect me to yell at them. I tell them to use whatever it takes. But I will not refer patients to chiropractors: I think there are other techniques available--physical-therapy techniques and exercises, as well as pharmaceuticals, acupuncture, and transcutaneous nerve stimulators."

Katherine Walsh is head of family practice at West Suburban. "I feel there's very definitely a place for chiropractic in holistic medicine. I think the ideal is to have the MD and the chiropractor working together. I feel chiropractors can be extremely helpful in treatment, particularly in cases where there is skeletal pain." She is unusual in that she does refer patients to chiropractors; but she likes to meet with and check out practitioners before she sends patients to them.

In medical school, says Walsh, "We were given a rather negative impression of chiropractors, and I feel that still prevails among many physicians. I tend to think that, in traditional medical school settings, chiropractic is still looked upon with disdain. But I went to medical school at an older age than the usual, and I was open-minded from personal experience. I just feel there's a lot of room for ancillary health care. I think it's important to be open to the possibility that there are other healing professions that can help the patient."

"The emphasis of the AMA is to protect the physicians and the drug companies that use the physicians," says a maverick MD who lives and works in Chicago and prefers to remain anonymous. "Most people don't know that the AMA only represents about half of the physicians in this country. A lot of physicians aren't buying the solutions that the AMA is pushing. The AMA is into suppressing alternate types of care, like homeopathy, acupuncture, manipulative therapy, nutritional therapy, and any other kind of therapy that is nondrug or nonsurgical and not controlled totally by the medical establishment.

"I think the AMA has picked the chiropractors as a group to attack, probably because they're easy victims. I don't really have anything to say about chiropractors--if a patient goes to a chiropractor, and they feel better, I have nothing to say about that. It's their choice; they make a free choice."

The courts found that the national Joint Commission on Accreditation of Hospitals was not guilty of antitrust, dismissing that portion of Wilk. Yet a few pioneering medical centers have begun to allow chiropractors on staff--moved not by altruism but by something much more basic: the profit motive. Hospitals are discovering that a significant portion of the public consider chiropractors their primary-care physicians--and in an era when it's getting harder to fill expensive-to-maintain beds, they want the referrals that chiropractors can provide.

There are also advantages for chiropractors--besides the feeling that they've gained acceptance and respectability. Chiropractors are able to maintain contact with, and a degree of control over the treatment of, hospitalized patients; and they gain access to expensive diagnostic equipment.

"The biggest problem we have in this profession is that we don't have a show like Marcus Welby to educate people, like the medical profession does," says chiropractor Richard J. Dietzen. "You'd be surprised by how influential a TV show can be!" Dietzen is head of Belmont Community Hospital's department of chiropractic, a subdivision of the hospital's family practice section. He helped to found the department in 1987, and there are now almost two dozen chiropractors on staff. "It's worked out very well, for a lot of reasons," he says. "But the bottom line is that it's best for patients to have a multidisciplinary approach to health care."

The roughest part of dealing with MDs, he recalls, came in the department's first six months or so--"when we were the new kids on the block," he says. "The MDs didn't know how to take us, because they didn't know much about us. But the barriers began to come down when we worked together and got to know each other.

"There was never a really hostile reception. I'd say I encountered three attitudes. Those MDs who were already working with chiropractors were excited about our coming in, some of the others were indifferent, and some were uncomfortable. There were a few people who said, 'I'm not working with you guys.' But one of those was an orthopedic surgeon who said after the first year, 'I want you to know that I've changed my mind and my attitudes on this, and I'd like you to put me on your referral list.'"

Dietzen predicts that chiropractors will soon be on the staffs of more and bigger hospitals. But it has to be done right or the project will fail. Northwest Hospital (later John F. Kennedy, and then Our Lady of the Resurrection) used to have chiropractors on staff--but no more. "They had a pilot program, but they never let it expand," says Dietzen. One motive was apparently to encourage chiropractors to refer patients to the hospital. "What some of the hospitals have done is set up a program with one or two chiropractors on it and send a letter to all the chiropractors in the area--'We have a department, refer us your patients.' But [Resurrection] never opened up that department to more than a couple of chiropractors, and the chiropractors caught on. Not only do they treat us like second-class citizens, they treat us like second-class citizens with very little intelligence." (Resurrection representatives did not return telephone calls about this issue.)

"I'd say it was six months or a year before I felt completely comfortable [working with chiropractors]," says Joseph D'Silva, an orthopedic surgeon at Belmont. "I was wary of them at first, but with time and discussion of their philosophy, we've been able to work together."

D'Silva is that rarity, an orthopedist who refers to "our colleagues, the doctors of chiropractic." He notes that his admiration is limited to those chiropractors who limit themselves to treating diseases of the spine. "I still disagree with chiropractic treatment of diabetes," he says.

D'Silva, who is also on staff at Swedish Covenant and Resurrection, which do not have chiropractors, says he would make referrals of patients to chiropractors when their conditions warrant it. "You will get a dichotomy still among MDs in their dealings with chiropractors--like anything else, it depends on interaction. And one of the benefits of having DCs on staff is the opportunity for interaction."

Is the medical doctor's age a factor in his or her acceptance of chiropractic? D'Silva, who is 37, thinks so--and not only the MD's age but the chiropractor's age is relevant. He believes that younger chiropractors have received a more scientific education than older generations and are more likely to limit themselves to problems of the spine--they make more realistic claims about the benefits of chiropractic.

"I think there really is a lot to be said for the DCs. Chiropractors do spend more time with the patient. They do more hands-on treatment. And that's a factor in healing."

Chiropractor Lawrence S. Levin helped start the chiropractic pilot program at Northwest Hospital (which was retained by John F. Kennedy and eliminated by Our Lady of the Resurrection). The hospital provided space, bought chiropractic equipment, and teamed him and a colleague with Per Freitag and an internist. "The program was extremely successful," says Levin. "It both helped patients and encouraged chiropractors to refer their patients to the hospital. We had over 300 admissions in a two-year period, which I'd say is extremely good. We worked closely with the physical-therapy department. It was my hope to establish a program within the hospital to give interns from National College experience in institutional care--because if this profession is to survive into the 21st century, we're going to need that experience."

Levin says he drew up treatment parameters for chiropractic departments that are now being used by other hospitals, including Belmont. The chiropractors at JFK limited themselves to treatment of the neuro-musculo-skeletal system. "We ended up dealing primarily with herniated discs," says Levin. "Over 75 percent of our patients didn't end up needing surgery--which I would call a major success."

When the hospital was sold, however, the new management didn't see the benefit of chiropractic. "Freitag left, and the program just evaporated," Levin says. Though chiropractors are still on staff, "We can't see patients--we can just refer them [to medical doctors]." But with Freitag gone, "There's no one to whom to refer." The problem, he says, is that most orthopedists are not as open as Freitag. "We understand medicine--we study from the same textbooks as they do. But they do not understand chiropractic.

"You can legislate, and you can hand down court orders, but you cannot mandate emotions. We just ran into a lot of stone walls. You cannot change or mitigate the attitudes of an entire profession when you're in competition with them. It comes down to money--every patient who comes to us is not spending their money with them."

Levin points out that, as an HMO physician, he's had exactly one patient referred to him--and that was a patient who had insisted on chiropractic treatment. "I have not felt any conspiratorial message being sent to us by the medical profession, but if they don't want you, they don't want you. You cannot just go into their ballpark and play."

It is important to note that the decision in Wilk v. AMA was not a judicial endorsement of chiropractic but an indictment of the AMA's anticompetitive activities. Parts of the chiropractors' suit were thrown out. The courts decided, for one thing, that hospitals are not obligated to permit chiropractors staff privileges. For another, punitive damages were not awarded--the plaintiffs gave up that claim, says McAndrews, so that the defense couldn't obscure the antitrust issue with accusations of greed. Each side charges the other with exploiting emotional issues.

"My impression is that Judge Getzendanner's decision was an emotional one," says William Tabor, former house counsel for the AMA, now practicing in Terre Haute, Indiana. "I think Judge Getzendanner thought with her glands rather than her brain. I think she did not have a very good understanding of medical ethics. She grasped onto every piece of evidence that was negative. The theory of chiropractic is still unscientific, and it always will be. It's baloney and no matter how thick you slice it, it's still baloney. She was never interested in understanding that. I think she looked at it on a visceral level, 'Here's this huge organization trying to destroy these poor chiropractors.' I think her decision was erroneous."

"He sounds like a sore loser," remarks Getzendanner, now in private practice. She categorizes Tabor's comments as "pretty sexist." "All the emotional play in the case was by the defense's lawyers. They really overplayed it with horror stories about how bad chiropractic was--chiropractors trying to treat brain tumors with cranial manipulation, that sort of thing. But that wasn't the issue, and I finally told them to cut it out."

The issue, she says, was the conspiracy by the AMA to "contain and eliminate" chiropractic. "They didn't deny there was a conspiracy. That is not in dispute. The stated goal of the Committee on Quackery was to destroy chiropractic, and they worked real hard at it for many years. The AMA's entire case was that it had ended its unlawful conduct in 1980, when they eliminated the principle that said it was unethical for an MD to associate professionally with chiropractors.

"I actually held that the conspiracy was over in 1980. Unfortunately, the AMA didn't tell anybody [that it had changed its policy]. I can tell, just by the mail I got--and to this day still get --that in 1987 most doctors were under the impression that associating with chiropractors was unethical, that I was the one who had lifted the rule. There was only one place where chiropractors were listed under the AMA rules [in 1987] and that was under 'unscientific practitioners.' So I held that, while the conspiracy was over, the injunction [to publish the change in the ethics rule] was still needed." The AMA has published the change in its official house organ, the Journal of the American Medical Association, but has yet to send the mailing Getzendanner ordered to all of its members.

Getzendanner, who says that neither she nor any member of her family has ever been treated by a chiropractor, says that her decision was in no way an endorsement of chiropractic. "I went out of my way to say that the court didn't endorse it--that wasn't what the case was about. Chiropractors are licensed to practice in all 50 states. Once the state legislatures licensed them, and permitted them to practice, that was all that was necessary from the court's point of view. The issue was the boycott--and it was really quite simple. At some point, you've got to stop trying to destroy a profession."

The former judge says she thinks the AMA was sincere in its animus against chiropractic: "I think they really did believe that chiropractic was bad. Their opposition was heartfelt. But their information was outdated. The AMA did not, during the entire period of the boycott, have reason to hold that view. It is clear that there were some therapeutic benefits of chiropractic that the AMA knew about."

Is this, then, primarily a turf battle? "Absolutely," responds Getzendanner. "Chiropractors compete with doctors. There's no question about it: it's basic competition."

"This is bigger than turf," says Mark Rust, a former reporter and editor for American Medical News who is now a lawyer. "The basis of Wilk v. AMA was economic entirely, but I think there's a lot more to it than the economic question. The typical physician reaction is benign--they don't have anything against chiropractors--but there are questions about staff privileges at hospitals, questions about standards, liability questions."

To Freitag, "It doesn't infringe on my income if chiropractors take some chronic-back-pain patients. If there's a turf battle, it's not between orthopedists and chiropractors, but between chiropractors and physical therapists. And even that is unjustified, because they do different things."

"The AMA is concerned about its survival, just as chiropractors are, and they're a massive organization--they're bigger than the Teamsters," says Levin. "I think eventually they'll duplicate chiropractic techniques in their own treatments; they're allowed to practice manipulation under the Medical Practice Act, even though they aren't required to study it. I think they'll work with their physical therapists, to keep their referral system safe. They know what they have to do to survive, and they'll do it."

Levin points out that there's a bill in Springfield right now that would permit chiropractors on medical staffs without requiring that they be supervised by MDs. "How can an MD sign a paper saying he approves of what you're doing when most MDs don't understand chiropractic?" He feels strongly that chiropractic colleges should offer MDs courses on the chiropractic profession--"to tell them what we do, and when they should refer."

What have been the effects of Wilk v. AMA on the chiropractic and medical establishments, and on the various practitioners of both disciplines?

Critic Stephen Barrett says, "The main effect is that it has made it very difficult for medical organizations to criticize chiropractors, or to interfere with their doing anything they want. The price is too high--that lawsuit cost [the AMA] millions of dollars."

"It's a little bit like early Christianity," says Freitag. "I'm sure if the Romans hadn't tried to stamp out Christianity, it might have died out on its own. If the AMA hadn't tried to ruin chiropractic, they wouldn't have forced bright people to look at it more carefully and find a scientific basis for it. [Fighting the chiropractors] was the worst thing they could have done. But the AMA really isn't a bad bunch of guys. Believe it or not, most of us in medicine are still somewhat altruistic."

An orthopedist who objected to the inclusion of chiropractors in the programs of the American Back Society remarked in a letter that, "In my opinion chiropractors should be regarded with faith healers and phrenologists in regards to their reliance on scientific basis for their practice activities. I felt it extremely discouraging that this group of practitioners would be given any degree of credence by being included on a program with distinguished physicians, such as you have assembled for your meeting. Particularly ridiculous are some of the topics including integrating chiropractic manipulation with rehabilitation and the writing of reports by chiropractors. . . . I won't be able to support your organization if this trend continues."

Aubrey A. Swartz, executive director of the society, responded in another letter: "We feel that the medical community would find it valuable to be aware of what osteopaths, physical therapists, occupational nurses, physiatrists, chiropractors, and many others are doing, as we feel that it would enhance one's own knowledge and skills. In particular, it would also help each of us understand when and who to refer certain types of cases to, with the best interests of the patient in mind. We feel that this process will ultimately result in improved back care, and the public, therefore, would be the ultimate beneficiary."

Says McAndrews, "The best result of this case is that you're starting to see more medical studies of chiropractic, more meetings at the academic level, and greater acceptance. The effect has been to jump start the kind of cooperation that should have taken place 20 years ago. It's great for the chiropractors. But the biggest beneficiary, really, is the patient."

Art accompanying story in printed newspaper (not available in this archive): illustration/Slug Signorino.

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