On July 1, Anita B. sent the College of Chiropractors of B.C. a request for response to correspondence sent April 12 and April 20, 2020, in which she identified herself as a BC client of chiropractic.  On July 20, Anita received a response from the college registrar, Michelle Da Roza, which can be found here.  The letter below is Anita’s response to Ms. Da Roza’s July 20 correspondence.

 

July 29, 2020

All Board Members and Registrar

College of Chiropractors of BC

900-200 Granville Street

Vancouver, BC V6C 1S4

Via email

Dear Ms. Da Roza and Board Members:

Thank you for your correspondence of July 20th, 2020 responding to my complaint letter of July 1, 2020. It is helpful to understand the CCBC’s perspective and I hope that this will be the beginning of a fruitful dialogue. I provide for you below my rebuttals to your responses to the specific questions I had posed in my complaint letter. Again, I ask that you ensure that all Board members receive this letter for their consideration and response.

  1. Why has the CCBC not responded to my previous correspondence?

You noted that my emails were addressed to multiple recipients with no specific questions for the CCBC. As is convention with email, any individuals, organizations, or other entities who are included in the “To” field are the specific addressees, just as would be the case had I listed them all at the top of this letter. All content of the email is intended for everyone to whom the email is addressed. I had identified myself as a resident of Burnaby, BC in my signature on the attached article, as well as in the email I had sent to the CBC, which was at the bottom of the same email string, and which I referred to in my covering email (“I had the below email exchange with CBC Vancouver.”) While I understand that receiving a response from other jurisdictions is less likely, I would have expected a response from the regulatory board that is mandated to serve me and protect my interests as a client of chiropractic in BC.

With respect to your comment that the CCBC did not note any specific questions for it, in my covering email, I had laid out the issue that I had discussed in the attached article. To quote directly from that email:

I am writing about my concerns regarding the obvious bias and skepticism regarding the efficacy of chiropractic in enhancing immune system function, as recently reported on by the CBC….

 At the above link, you will find a collection of 114 citations for studies and articles pertaining to the connection between chiropractic and the immune system….Now that you have this information at your disposal, please do not dismiss it as spurious or insufficient, or endlessly demand higher standards of proof….I am all for critical thinking and consumer advocacy, as long as every effort is made to maintain an unbiased and balanced perspective.

 It is ironic that the news organizations, universities, regulatory bodies, and advocacy groups purporting to protect the public against misinformation are the very organizations the public needs to protect itself against….

 I would like to see some positive action taken on this:

  • to the regulatory colleges and associations, please address this matter at your next board meetings and I would like to hear back from you on how this is to be remedied

Regarding your comment that my emails related to a CBC news story, the CBC obtains information for its news stories on chiropractic, in part, from the regulatory bodies. I had attached to my complaint letter an email exchange I had had with Paul Hambleton, Director of Journalistic Standards for the CBC. In that email, he noted that the issue of chiropractic vis a vis immunity is dealt with by the regulatory boards. To quote from his email:

You write with detail and conviction that chiropractic treatment does boost the immune system through spinal adjustment and releasing stress. While you cite scores of articles that you feel prove that is so, it’s not a view shared by…the College of Chiropractors of British Columbia, or the Alberta College and Association of Chiropractors, or the Manitoba Chiropractors Association, or the L’Ordre des chiropraticiens du Québec. In fact, all of those governing organizations have issued statements in the past few weeks warning their members not to spread misinformation about boosting immunity and the coronavirus.So, your argument that chiropractic treatment does boost the immune system is a contention that should properly be taken up with the chiropractic governing bodies.

Therefore, because the CBC relies largely on the regulatory boards for its information, while I do not release the CBC from the negative and biased manner in which it presents the information, any issues I have with respect to the chiropractic news stories released by them ultimately come back to the regulatory boards, including the CCBC. While ostensibly my article was directed at the CBC, the issues raised are also for the consideration of the regulatory boards across the country, particularly the CCBC, since I am a resident of BC. I am still eagerly awaiting your response as to how the CCBC will address the issue of censorship of chiropractic with respect to immunity. I do hope we can refrain from ‘buck-passing’ and instead work together to resolve the matter by addressing it as effectively as possible within our respective spheres of influence.

Please note that I have been a federal public servant for almost 22 years[1]. By definition, I serve the public. Over the course of my career, I have had the privilege of working with volunteer groups, non-profit organizations, non-governmental organizations, industry groups, and Indigenous peoples. I have on occasion received correspondence from angry and frustrated individuals. I respond as thoroughly as possible, addressing all issues raised, whether any explicit questions have been asked or not. I would appreciate the same from the CCBC. I find that not doing so only increases their irritation and escalates the conflict. I do find it irritating that the CCBC did not respond even to all of the matters I raised in my complaint letter, despite the fact that I asked for a response to all of my correspondence, as well as to those explicit questions. The CCBC instead chose to limit its response to my list of questions. That is unsatisfactory. It also leaves that impression that the CCBC is protecting itself, rather than protecting my interests. Clearly we have a different understanding of what it is the public needs to be protected from.

  1. Why are chiropractors being limited in what they are allowed to discuss with clients?

Thank you for the references you provided, that is helpful.  As I noted above, I am a federal public servant. As such, I am a representative of the federal Crown, I am bound to a particular code of conduct, and I am expected to be loyal to the Crown. I understand the constraints the CCBC is under with respect to legislation passed by the provincial Crown. At the same time, I also know that no policy, bylaw, nor piece of legislation is cast in stone. Even the Canadian Constitution has been amended. I also know that policies and bylaws passed by the CCBC are less rigid and far more easily amended than acts, laws, and regulations passed by the Crown. Where these documents are not in line with the current reality, they need to be amended. Rather than restricting chiropractors to bring them back in line with outdated rules, the rules must be revised to reflect advances and new evidence, and to clarify any verbiage in those documents that is too broad and/or is being inappropriately or unjustly applied. I note that the CCBC’s Bylaws were last updated on May 20, 2017 – more than three years ago. Based on my analysis below, I suggest that the Bylaws – and consequently, chiropractors and their clients – would greatly benefit from an update.

You quoted s. 85 of the Bylaws:

Under s. 85 of the Bylaws, registrants must not engage in marketing that is false, inaccurate, unverifiable, misleading or misrepresentative of the effectiveness or a technique, procedure, instrument or device.

Again, thank you for pointing to this section in particular. This is the crux of the issue. What I as a satisfied client have experienced and know to be true, the CCBC is censoring as “false, inaccurate, unverifiable, misleading or misrepresentative of the effectiveness or a technique, procedure, instrument or device.” With respect to marketing, I suggest that the CCBC clarify what is truly marketing versus dissemination of information. At what point does educating the public on the potential benefits of chiropractic become marketing? If clearer guidelines could be developed to distinguish the two, that would likely be helpful.

However, a fundamental problem is that the CCBC does not accept evidence about the efficacy of chiropractic with respect to particular conditions. That is problematic with respect to s. 85(3)(b):

“Without limitation, marketing violates subsection (2) if it (b) is likely to create in the mind of the recipient or intended recipient an unjustified expectation about the results which the registrant can achieve.” By default, what a chiropractor would put forward as education regarding those matters, the CCBC would forbid as false advertising.

This section also contradicts the Code of Ethics in the CCBC’s own Professional Conduct Handbook:

  1. A chiropractor will show concern for human caring and, whenever possible, will involve patients in decisions relevant to their care.
  2. A chiropractor will practice the profession to the best of his or her ability, and will continue to educate himself or herself in order to improve clinical competence and assure the confidence and respect of patients.
  3. A chiropractor will, in the public interest, preserve, protect and communicate the expertise of the profession in legislative, public education and research matters.

How is a chiropractor to fully involve a client in decision making, practice to the best or his or her ability, or communicate the expertise of the profession to the best of his or her ability when they are being censored and restricted in what they are permitted to discuss and treat?

What further confuses the issue is with respect to testimonials:

14.3 Chiropractors may use testimonials in marketing activity provided (a) they obtain written permission to use a testimonial from the patient providing it, and (b) all testimonials are truthful, accurate, in good taste and otherwise conform to the provisions of the Handbook and section 85 of the Bylaws.

Who is to decide what is truthful or accurate? If the testimonials are to conform to the Bylaws, even the clients would be censored so that their testimonials of their own experiences are in line with the rules. In fact, if I were to censor my testimonial and not discuss those benefits I have received that the CCBC does not accept as being scientifically verifiable, my testimonial would not be truthful, but it would conform with this provision. If I were to write a testimonial regarding benefits regarding digestion, sleep, emotional matters, vocal function, etc., that is, matters beyond musculoskeletal, would my chiropractor make himself vulnerable to penalties regarding false advertising? Would he be splattered across the news as Dr. Sullins was, with photos of testimonials regarding benefits related to ADHD, whether that was a targeted condition or not? If that kind of testimonial is acceptable, then why is my self-reporting not sufficient as ‘acceptable evidence’ to allow him and other chiropractors to make claims regarding the efficacy of chiropractic with regard to those issues, particularly where scientific research is lacking? I discuss this further below.

The items I noted from the Handbook relate to those I pointed to in my letter from the Patient’s Charter of Rights. Ideally, chiropractic services would be offered in line with the Patient’s Charter of Rights and with the Code of Ethics. Section 85 of the Bylaws, however, puts severe restrictions on what chiropractors are allowed to communicate. Again, how can there be informed consent if the chiropractor is not allowed to discuss matters or offer services not ‘proven’ by science? How is the client to be fully engaged in decision making when the chiropractor is not permitted to discuss the full scope of options and the current state of knowledge of chiropractic where research (or lack thereof) continues to be controversial? How can the chiropractor practice to the best of his or her ability when their ability is being restricted to ‘proven’ services and information? That does not serve the public interest.

Given the very limited resources the chiropractic profession has to conduct research to demonstrate benefits other than musculoskeletal, that is why I raised the critical nature of accepting self-reporting as valid evidence to support these claims. I find it offensive that such claims are often written off as placebo, i.e., as imagination, rather than being real outcomes. As I noted in my latest article, even the Harvard School of Medicine recognizes that outcomes realized in response to a placebo do not indicate that the treatment was ineffective, but rather that the response was realized through a different mechanism.

With respect to immunity in particular, I wrote at length in my articles about the complexities of the immune system and of the various ways that we can fortify ourselves against any illness. I ask the CCBC to take a much broader view of how chiropractic can be effective in increasing immunity and promoting overall wellness. Chiropractic should be understood as a valuable tool to promote health and wellness, and it does so over variable timeframes, depending on an individual’s condition at the outset. Stress relief through pain relief or through improved sleep as a direct benefit of chiropractic, for example, most certainly increases my capacity to ward off illness. I know when I am under more or less stress whether that can be measured accurately in a scientific study or not. It is frustrating and nonsensical that an individual wholly unconnected with me is deemed to be better qualified to report whether I am feeling stressed.

In addition to my personal experience, in my second article, which was a rebuttal to Ryan Armstrong, I wrote a critique of the World Federation of Chiropractic’s “Rapid Review” of the literature respecting chiropractic and immunity. I noted that a number of the studies reviewed did provide clear evidence of immune system activity in response to chiropractic, and in no cases was there clear evidence against it. In all cases, the criticisms the WFC put forth were questionable. In short, the evidence does exist. It is being ignored.

You note that the CCBC was concerned about claims where there is ‘no acceptable evidence’. I have often heard the complaint from chiropractors that no entity governing chiropractic has put forth any guidance on what is ‘acceptable evidence’. Therefore, any evidence that is presented is easily dismissed as not meeting some non-existent standard. Who is to judge whether the evidence is acceptable? Who sets that standard? Is it the CCBC? The WFC? The Minister of Health? Regardless of who is setting out what is acceptable, I again stress that where no conclusive scientific evidence exists, the best available evidence is the self-reporting of the clients. That must be the acceptable evidence that allows chiropractors to make those claims. Otherwise, clients will be deprived of treatment that may very well be of benefit. If the CCBC is defining what is acceptable evidence, I ask that they incorporate that perspective and to make those standards widely available to the profession and to the public. I also implore the CCBC not to be influenced by skeptics like Tim Caulfield and Ryan Armstrong who are not clients and have a clear agenda to severely restrict and dismantle the profession.

With respect to the legislation, I am well aware that the CCBC does not have the authority to unilaterally amend it. It does, however, have the ability to raise concerns with the Ministry of Health where the legislation is unclear, too restrictive, outdated, or that generally is not in the public’s best interest. The clients are best placed to report when the rules are not serving their needs nor protecting their interests. I am doing so now. When clients bring valid concerns forward, they should be brought to the attention of the Ministry of Health and escalated as appropriate. I am copying the Minister and my MLA on this letter and will be addressing them directly in separate correspondence.

All that being said, I am not seeing anything in the Health Professions Act that puts the severe limitations on chiropractors that they are currently experiencing. According to the Chiropractors Regulation, Part 4 of the Act relates to chiropractic. Part 4 is entirely administrative and relates to business practices, not chiropractic care. That would suggest that the limitations on chiropractic are coming exclusively from the CCBC. Is there something happening behind the scenes between the Ministry of Health and the CCBC that the public should be made aware of regarding restrictions on chiropractic? Is the CCBC being lobbied by skeptics or by the medical profession to restrict what chiropractors may discuss or treat? What has happened suddenly to bring about these restrictions and censorship, which are not in line with the governing legislation?

Regarding valid concerns, rather than citing policy, bylaws, and legislation, would the CCBC please identify for me from a logical perspective where it deems my concerns to be invalid? Does the CCBC disagree with any of the arguments I presented in this letter, in any of my cover emails, or in any of my articles?

 Rather than presenting you with an extensive list of questions, I ask that the CCBC carefully read through my articles and identify any points that you disagree with. I believe that to be the most expedient approach for all. The CCBC has been in possession of some of those articles for months. It is unfortunate that they were not addressed in full as they were received.

  1. Why are chiropractors being limited to giving only treatment that has been scientifically tested and shown to be effective when the same is not true of the medical profession?

You noted that chiropractors are governed by the Chiropractors Regulation. I found it very interesting that the Chiropractors Regulation defines ‘chiropractic’ as relating to not only musculoskeletal issues, but also to the nervous system. It allows for assessment of the nervous system, the treatment of it, and advice and counselling related to it. The nervous system controls all aspects of our being. As I asked in my most recent article, how is a chiropractor to prevent any influence on the nervous system in the course of treatment of any musculoskeletal issue, given innervation of every muscle in the body and the 100 trillion neural connections in the brain? As well, I recently became aware that the CCBC is questioning the needs for routine X-rays as part of chiropractic treatment, yet under s. 4(1)(f)(ii), chiropractors are explicitly authorized to employ X-rays for diagnostic and imaging purposes.

How is it, then, that the CCBC has been forbidding chiropractors from speaking about matters relating to the nervous system and any illnesses of the nervous system, when even the regulation under the governing legislation allows for them to do so? Why is the CCBC questioning the use of X-rays when that is also permitted under the regulation? Did the Minister of Health ask for input on that? Is the Ministry aiming to amend the regulation? If not, how are the CCBC’s regulatory actions to prevent practices that are clearly described in the regulation as being part of chiropractic not ultra vires? By what authority is the CCBC regulating chiropractic contrary to the Chiropractors Regulation?

  1. Why are accepted standards of practice not sufficient, as they are with the medical profession?

Your response does not answer my question. What I am asking is why is there a double standard? I recognize that CCBC is not in a position to speak on behalf of the College of Physicians and Surgeons. That said, I fail to understand why chiropractors would not be afforded the same latitude as medical doctors in the absence of scientific evidence. Chiropractic is non-invasive and does not pose the same risks as those presented by pharmaceuticals or surgery, yet they are apparently not seen as equally trustworthy or competent as medical doctors in deciding an appropriate course of action. Why not? Why does the CCBC feel the need to put tighter reins on a non-invasive and relatively gentle practice?

  1. What is the source of the negative bias against chiropractors?

You stated that the CCBC is not an advocacy organization. This is not about advocacy. This is about effective public policy, clear guidance for acceptable evidence, critical thinking, logical reasoning, unbiased regulation, and bringing to the Minister’s attention matters that are problematic and require resolution. I have been told by those in a position to do so that the CCBC does not challenge any decisions made by the Minister of Health, but rather implements all decisions unquestioningly as a means of being accepted by the Minister, and there are no dissenting members on the board. This approach serves only to protect the interests of the CCBC itself. A board of “yes men” mainly interested in self-preservation does not protect the interests of the public.

The CCBC may well feel itself to be in a vulnerable position. I would argue that being merely an administrative arm of the Ministry of Health also puts the CCBC in a vulnerable position, as it adds little value. Governments are well known for cutting programs and processes that they deem to be ineffective uses of public funds. One potential function that would be most welcome would be to work more actively with the public, and most particularly with the clients, to have fulsome discussions regarding matters of concern. This relates to the Patient Relations Committee, which I discuss below under item 7.

  1. Why is the input and experience of clients not accepted as relevant in determining the efficacy of their own personalized chiropractic treatment?

You noted that CCBC supports Evidence Informed Practice which is composed of 1) the best external evidence, 2) the individual practitioner’s clinical expertise, and 3) patients’ preference. I had identified the same three elements in my complaint letter. This relates to my discussion above regarding ‘acceptable evidence’. Where controlled studies have not taken place due to a lack of resources, where results are inconclusive, or where the results are simply deemed ‘not credible’ with no rationale for doing so, self-reporting should be accepted as the evidence that allows chiropractors to offer their services as a means to address a given condition, rather than disallowing it under the CCBC’s Efficacy Claims Policy. It could be many years before such treatment is ‘proven’, which then eliminates chiropractic as an option for patients, thereby limiting their right to choose their own health care.

As well, as I noted in my second article, science can not ‘prove’ anything. It can only demonstrate outcomes under specific conditions and assumptions, conducted by particular researchers on a given set of individuals. No treatment is effective 100% of the time for 100% of patients, yet it is still available. Some cancer treatments, for example, have a less than 50% success rate, yet are still used. There is no reason to set higher standards for chiropractic, particularly given that it is far less risky to a patient’s health than is cancer treatment. The argument that risks outweigh benefits is one that should be left entirely up to the client, based on a policy of informed consent, i.e., informed by all available sources of information and not only scientific studies that ‘prove’ efficacy based on a non-existent standard.

  1. Why is the Patient Relations Committee’s mandate limited to sexual misconduct?

You noted that that limitation is proscribed by legislation. The wording of s. 16(2)(f) does not expressly forbid the CCBC from expanding discussion at committee meetings beyond the matter of sexual misconduct. That is merely the one particular item that is a legislated requirement. This is not a valid legal reason to limit the committee’s activity to sexual misconduct exclusively. Expanding the committee’s mandate is more a matter of political will than a legal impossibility. Even informal discussions on matters for which the CCBC is not legally responsible would be mutually beneficial, by allowing clients to bring concerns to the CCBC’s attention and to obtain feedback from the CCBC on how such matters may be addressed. It would be greatly appreciated if the CCBC would explore its options in this regard.

  1. Would the CCBC consider expanding the Patient Relations Committee’s mandate to include any and all client concerns related to chiropractic, including the regulation of it? If not, why not?

Please see my response above. A willingness to hear matters beyond sexual misconduct would also provide a more efficient forum for addressing such matters, and would reduce the need for extensive letter-writing for both the public and for the CCBC. There is nothing in the legislation nor bylaws that dictates the structure of meetings. An open forum, at least occasionally, that provides an opportunity for those outside the committee to speak and to fully engage with the committee would be most welcome. An open invitation and time reserved on the agenda for members of the public to have an open discussion with the board at every CCBC board meeting – and not just the annual general meeting – would also help to address the need.

With respect to the other mechanisms you noted for lodging complaints, how exactly are broad concerns regarding the CCBC’s policies and processes dealt with? How are they investigated and who is involved? Who was involved in drafting the CCBC’s response to my complaint letter? Please outline for me the process for addressing complaints against the CCBC versus the process for complaints brought against individual chiropractors.

I would like to reiterate that I hope to have a fruitful discussion with the CCBC, rather than interviewing you with a long series of questions. I ask again that you give serious thought to all of the issues I’ve raised in my emails, letters and articles, and not just the explicit questions, and to provide me with your views. That would demonstrate to me – as well as to the public – that the CCBC is sincere in delivering on its mandate to serve and protect the public interest with respect to chiropractic.

Once again, I look forward to your timely response.

Sincerely,

Anita B.

Concerned Citizen and Grateful Recipient of Chiropractic Care

 

 cc:

Honorable Adrian Dix, BC Minister of Health

Honorable Katrina Chen, MLA Burnaby-Lougheed

BC Chiropractic Association

Dr. Amy Robinson, Canadian National Association of Chiropractors

Alison Dantas, Chief Executive Officer, Canadian Chiropractic Association

Dr. Ayla Azad, Director of Professional Practice, Canadian Chiropractic Association

Tari Stork, Director of Public Affairs, Canadian Chiropractic Association

Robert Harris, Executive Director, Canadian Chiropractic Research Foundation

 [1] At no point in my career has my work related to any aspect of individual or public health. There is no conflict of interest with my advocacy work.