The end of average care

Once upon a time, a patient of mine had a sodding enormous dog called Loki.

An English mastiff, they can weigh as much as 25 stones or 155 kg, like this chunky monkey, Zorba.

Imagine him as a lap dog……

Literally the size of a small horse.

Anyhoo, as much as he loved Loki, he didn’t love the vet bills.

Flea injections, anti-biotics etc etc are all size dependent dosing, so more dog = more drugs = more cost.

It has to be that way, personalised care, or if they average it out, Loki (and Zorba) wouldn’t get a therapeutic dose, and the small, yappy type dogs would be off their tiny minds.

So if it’s good enough for dogs, it should be good enough to personalise care for humans, shouldn’t it?

A recent headline posted by an academic from one of the Chiropractic institutes, you know the type, never actually touched a patient but is telling us what does and doesn’t work……on average.

The headline read:

MRI and X-Ray Often Worse than Useless for Back Pain

Medical guidelines “strongly” discourage the use of MRI and X-ray in diagnosing low back pain, because they produce so many false alarms.

I stupidly took the bait and read the article.

In reality, it’s about medics in America and the overuse of MRI’s to diagnose the cause of pain.

But this really has nothing to do with our practice.

Though there were plenty of DC’s commenting/projecting their insecure egos all over the post.

From the content, the vast majority hadn’t even actually read the article.

But the thing that caught my attention was the definitive use of a headline to create a black & white/binary scenario in clinic (non-clinicans & the borderline clinically inept, who claim to be “evidence based” do that a lot)

On AVERAGE, x-rays and MRI don’t help to diagnose the cause of pain.

So my take is this: Who wants average care?

How many average patients do you see in clinic?

None. It’s a statistical midpoint.

The further away the patient is from the middle of the bell curve, the worse it will be for them.

Chiropractic has always been personalised care.

I mainly x-ray to help rule out pathology, plus some bio-mechanical info in some patients (when appropriate).

If you have ever diagnosed pathological or post-traumatic fractures previously missed by A&E you will know the “what if’s” thoughts running through your mind.

It’s scary stuff.

I can still vividly remember the face of the gentleman I examined with severe headaches (already seen x2 medical Doctors in last 4 days), as I said “is your eye lid a little droopy….?”

He was later diagnosed with a dissecting carotid artery after I packed him off to the doctors.

Another thread from a FB group also questioned the need for Chiropractors to even take or use x-rays in their own clinic.

Ultrasound, CT and MRI were the imaging of choice.

And yet it was painfully obvious in the ensuing comments, those who had a decent amount of clinical experience and had actually used x-rays and picked up plenty of missed NHS diagnoses.

Vs those who know no different from practicing without it.

Yes you can always refer out, but are you less likely to do that if you do not have it in-house?

I do not want or need an academic, or non-practicing DC posting from their ivory research tower, about a non-existent, black and white world where you treat by averages.

Remember the map is not the territory.

Maps are a simplification of the terrain you wish to walk. In order to make it usable it must be a gross simplification of reality, it cannot be reality or it would not be a map.

If you want to be a master clinician you need to learn to live on the edge of clinical uncertainty.

Get comfortable being uncomfortable.

We care for individuals with totally unique issues, that may follow certain patterns that respond to similar care, but each visit should be bespoke to some degree.

Test, treat, re-test, repeat.

If your technique theories are as good as you think/say, then you should have no anxiety about showing it to the patient in the room before and after care.

Nowhere can the folly of averages be seen better than blood test results.

Take a group of “healthy” people (healthy is a relative term, they mean asymptomatic) and the 95% in the middle are “normal“.

The 2.5% either side are low/high respectively & thus are abnormal.

But I don’t want to wait until my patients are so ill they are finally diagnosed with a blood test.

To me, that is unethical (plus some never get so low they actually get treatment but still become disabled or die from it).

I want to catch them as they are headed down/up & optimise them and give them their life back.

Vitamin B12 is a perfect example of this.

According to the NHS if you are over 160 pmol/L ish (this varies between labs) you are fine (kind of).

(They do actually say if neurological symptoms are present but results are normal they should treat with B12 injections, but I’ve only seen this happen once in 22 years.)

But in reality, optimal probably is in excess of 650 pmol/L and maybe much higher in certain patients.

If they are under 500 pmol/L, and have symptoms that fit B12, ALWAYS treat.

Without B12 you can’t make myelin.

Think about that for a second.

MYELIN

Good luck improving the neuro-mechanical system and symptoms with slowly disappearing myelin due to a “normal” B12 level.

Neurological damage from B12 deficiency can be permanent.

Just ask Charlotte, currently suing the NHS for missing her B12 diagnosis and mis-managing it.

Click the image & hear her story, I dare you.

I have seen many times patients with “grey zone” B12 between 160-500 pmol/L, go from tired, depressed, in pain to happy and pain free.

Including patients with what looked like cervical myelopathy and a +ve hoffmans sign, disappear after B12 liposomal liquid.

So keep doing what you know is right, never treat averages, always bespoke the care you deliver & ignore non-clinicians telling you how to practice.