Ask Yer’ Uncle Panda….

Say Uncle Panda, I notice you haven’t written about chiropractors. What do you think about them and chiropractic in general?
Chiropractors serve a useful role in society, particularly when it comes to taking some of the pressure off of used car salesmen who would otherwise have the market cornered on chicanery. Nobody likes to be the only crook in town you understand, and if chiropractors are good for the self-esteem of used car dealers I’m all for ’em. Other than that there’s not much use for chiropractors except to keep second-rate strip malls in business as they make that long descent from shopping mecca to consignment stores and karate studios.

On one hand you have the straight chiropractors who preach a strange religion where manipulating the spine can take the place of vaccines and cure all manner of diseases from cancer to your Aunt Dottie’s lumbago. On the other are the so-called “reform” chiropractors who confine their practice to musckuloskeletal complaints. Six of one, a half dozen of the other. Despite the occasional studies showing that it has a slight advantage over placebos in the relief of chronic pain and other fuzzy symptoms, chiropractic is a lot of sound and fury signifying little or nothing. For the money people spend and the effort they put into it (chiropractic school is four years, after all) I guess I’d want a little more than a slight improvement over a placebo. Just for my self-respect, you understand.

The basis of chiropractic is the theory that misalligned vertebrate (called “subluxations”) are responsible for disease. The old school chiropractor will shoot a plain film of your spine and use this as a basis for manipulating it back into position despite the overwhelming evidence that not only do otherwise healthy people have asymptomatic misalignments in their spines but there is no way to change the alignment anyway short of orthopaedic surgery.

But do what you want. I don’t care.

Hey Uncle Panda, I’m considering Emergency Medicine but I’m concerned that it’s just glorified primary care. What say you?

That’s ridiculous, at least from my perspective. As many of you know, I did a year of Family Practice and while I disliked it intensely, it at least gave me a taste of primary care. Emergency Medicine is nothing like primary care.

Here’s what I saw on a recent shift: Two acute MIs (one with significant ST elevations), one acute pancreatitis with nausea and projectile vomiting, a baby with meningitis and CSF that looked milky when I did the lumbar puncture, a motor vehicle accident with bilateral tibia fractures, a tylenol overdose, vaginal bleeding that turned out to be an incomplete abortion, a couple of strokes, a severe COPD exacerbation, a third nerve palsy (which I diagnosed without an MRI, thank you very much) and the usual minor stuff which, although minor, was still more “urgent” than the usual primary care fodder.

People go to their family doctor for diabetes management. They go to the Emergency Department for diabetic ketoacidosis or when their foot is rotting off as a consequence of distal peripheral neuropathy. That’s the difference. I think I see more truly sick patients in one week in the Emergency Department than I did in a year of clinic in family medicine where, on the rare occasion when somebody was really sick they got sent to the Emergency Department.
Now, it’s true that a lot of our patients could be better served at an Urgent Care. On the other hand one of our biggest source of customers are the local Urgent Care clinics, many of which are staffed by midlevels who have the good sense to drop back and punt.

I think a lot of folks don’t really understand primary care which is the long-term management of chronic conditions and not something we do in the Emergency Department, even if we wanted to which we don’t. We refer to primary care almost as much as they refer to us.

The truth is that you get so used to really sick patients that it begins to seem like primary care.

I am not busting down on primary care and Family Practice in particular. Primary care is neither easy nor quick. That’s why residency-trained physicians need to do it. The reason mid-levels do it is because nobody else will and because, cobra-like, they have mesmerized the Family Practice physicians who are their natural prey into accepting them as equals.

How long does it take to write an article for your blog and where did you learn to write so well?

Some articles write themselves and some I have to sweat over for days. I do experience periodic writer’s block and can go a long time without a decent idea (like the past couple of weeks). I suppose I could always write about how much residency blows but I don’t want to be a one trick pony. Besides, that would be like playing a crowd for cheap laughs. It’s too easy.

I also write most of my articles late at night when I should be sleeping. I hope that you, oh my critics, appreciate this when I don’t provide footnotes and an exhaustive bibliography. I just don’t have time. And I blog for fun so while I feel a responsibility to my readers to provide interesting articles, I do have a real job and to be honest, I make more moonlighting for half an hour than I do from the advertisments on my blog for a month.

In other words, this blog is a labor of love and not a money-maker so sometimes responsibility trumps fun.

I am flattered that many of you think I am a good writer. Let’s just say I’m working on it. I have pretty good role models who include Herman Melville, Mark Twain, Anthony Burgess, George Orwell, Charles Dickens, and Joseph Conrad to name a few. People ask me what I think about the Da Vinci Code. I didn’t read it. I don’t read crap. Period. I used to, of course, but after I discovered Robert Graves I have never looked back.

Read the first page of “Bleak House” or “1984” and compare it to the typical offering at Barnes and Noble and you will see what I mean. Most writing, like most popular culture, is excruciatingly bad. Almost painful to read. I’m probably not too much better but at least I can see where I need to go. One day I will have time to really write something meaningful but not right now.
Paradoxically, the rest of my tastes are completely plebian.

36 thoughts on “Ask Yer’ Uncle Panda….

  1. i once had a chiropractor tell me, “if i get a patient from the time they are born they will never get sick.”

    good on you for calling a spade a spade.

    from my perspective if someone believes something helps them and they do not want to listen to reason then fine, go ahead. the thing that irks me is that these goofballs get money up front. they get paid every time. i wonder, in the end. who’s smarter.

  2. 911doc – said DC needs to have his spine adjusted by a couple of feet in separate directions.

    And not to sound like a dyed-in-Kool-Aid fan here, but damn, do I love my Uncle Panda. I was just having a conversation with a friend of mine about how “pop culture” and that which it entails is often crap.

  3. I’ll disagree, just to offer my 2 cents.. Ive grown up with a couple of DCs in my family, and always had good quality care and relief of symptoms after get cracked on. I am biased, and freely admit it.. Also, my DCs practice Applied Kinesiology, and personally, i think that separates the quacks from the DCs that actually know something about medicine.

    and thats my 2 cents.. any debate points?

  4. Applied Kinesiology is the same old stupid shit wrapped up in a new name with a big ole bow tie slapped on it. A DC developed it in the 60’s.
    DCs are about as useful as trained masseuse’s, except a masseuse is cheaper and won’t dose you with radiation from an xray.
    Personally, I’ll take sex and a milkshake, but some people feel the need to go pay quacks to feel better.

  5. It is not wise to denigrate pop culture. Though I am in full agreement as to the true nature of Dan Brown’s output, there was a time when many a writer was considered a hack. Shakespeare’s plays were once enjoyed by the same segment of the population that now watches Fear Factor and day time television. Even Faulkner, whose work you allude to in this post, was once considered a cruddy writer. If anything, pop culture, including MTV and that barricade of excrement you have to wade through at grocery store checkout lines can be useful as barometer of zeitgeist—the oversoul of your clinical population.

  6. You diagnosed the 3rd nerve palsy through abnormal position/movement of the eye? We studied that in neuro and I thought it was interesting, but I’d have to look it up to be sure I had the right nerves (although the names of the two exceptions are pretty self evident). Did the patient offer a cause when you took the history? Recent accident or sometthing? What causes a 3rd nerve palsy?

  7. I have never read anything by Faulkner and any allusion is purely coincidental.

  8. Then I highly recommend his The Sound and the Fury, which takes its name from Shakespeare’s Macbeth (Act 5, Scene 5):
    “To-morrow, and to-morrow, and to-morrow,
    Creeps in this petty pace from day to day
    To the last syllable of recorded time,
    And all our yesterdays have lighted fools
    The way to dusty death. Out, out, brief candle!
    Life’s but a walking shadow, a poor player
    That struts and frets his hour upon the stage
    And then is heard no more: it is a tale
    ”Told by an idiot, full of sound and fury,
    Signifying nothing…”

  9. Yeah, but see, I’m referencing Shakespeare, not Faulkner. It’s like ascribing “for whom the bell tolls” to Hemingway, not John Donne.

  10. I think chripractors should be shot in the head….

    Anyway when I was a kids once I woke up with a very stiff neck, i couldnt even turn it 5 degrees without excruciating pain – went to a chiro and he fixed it right away….

    anyway i think anyone but md’s should be called “doctor” for example my priest is a “doctor of divinity” what kind of bullshit is that?

  11. dr. bear, have you heard about one of the republican candidates, Dr. Ron Paul? I was wondering what you thought about his ideas about how to fix the health care system.

  12. dr who, the word doctor comes from the Latin “docere,” meaning to teach. It’s a title that refers to anyone highly educated, basically a scholar, and has been used that way for centuries. Now that physicians are highly educated enough to get to use the title, physicians are often the only “Doctors” that most people come into daily contact with, and so it gets used most often with them. That doesn’t make the original use of the word incorrect though.

  13. I guess it depends. In terms of the books being way too long and going off on incredible tangents, Melville would be a candidate. However, in terms of writing like your in 1st grade, Hemmingway wins:

    As might be said in say “The Old Man and the Sea:”

    “Man. Yes boy. I want to catch a fish old man. I do too boy. Okay man. Yes Boy. Etc…..” (This isn’t actually a quote)


    My Biochemistry textbook was more dynamic.

  14. Hm… you do have a point there. I couldn’t get through “Snows of Kilimanjaro” even though it’s relatively short. I do think though, that in terms of sheer mental pain due to reading, Melville wins because the books are so long that you want to take your own life by the time you get to the end… if you have the stamina to get that far.

  15. Yeah, I’ve fortunately never gotten all the way through any Melville. The only reason I got through any Hemmingway however was a mean spirited high school teacher who thought it would be good for me. Lo these many years later, I still bear the scars.

  16. another people who should be called doctors: dentists (they have no md either) – i dont believe in them!

  17. Robert Graves all the way! I’m glad you discovered him, he’s such a great writer 🙂

  18. I remember an ER doc angrily yelling out in the work area “Don’t ever mention the word Chiropracter again when I am in the same room!”

    I don’t know what precipitated his outburst but I could see that he was serious.

    Great blog! 🙂

  19. I like how literary the talk is getting… milky orgasms and shit…I have fallen on very hard times with personal reading, can’t get into anything unless it is too interesting to put down…I would have to be facing a firing squad to finish anything about a psychotic whale and the problems of shipping vessels in the 19th C. But when I do finally find something, it’s like an orgy…

    My latest dry spell which went on for months
    was broken by Gawande’s “Complications”. His description of learning to do central lines mirrored my own experience, practically word-for-word. And the botched tracheotomy makes for some rather tense reading. I read it while hiking with the family, it was challenging but the only thing to do.

    And before that Michel Houellebec’s “Whatever”
    devoured me in a few hours. Much better than Fitzgerald for spare beauty, and much meaner towards the sexes and their sexes. Author is also openly hostile to popular culture and islamists, which means he won’t live much longer.

    About chiropractors, my last indirect encounter last month involved a rather limited elderly gentleman patient presenting with infected ulcerations over three of his spinous processes, resulting from the use of an “activator” device the day before at the chiros’s office.

    So they aren’t at all popular with me, now or ever.

  20. In defense of Melville… The first time I read Moby-Dick was as freshmen in college. It was an excruciating ordeal in which I had to skip whole chapters and I still never finished it. About six years later I gave it another try and found it to be a movable feast as applicable to our times as it was when it was written in 1851. If Melville was writing today then he would be writing about the Ahabs of Araby or perhaps a monomaniacal quest for petroleum rather than whale oil. Check out the interesting commentary on NPR concerning Moby-Dick:

  21. No, it was that writer-imposter Hemmingway. Who, by the way, was successful because so many deaf and head-injured vets could read and understand him. Just my opinion.

    I mean, what kind of book was “the old man and the sea”, seriously…plot akin to long long slow almost bare train that comes into the station empty…FUCKING brilliant!!!
    Talk about the absolutely humorless staccato drone of a depressed alcoholic.

    Even at age 12 when I read it I knew something was seriously wrong there.

    I am going to venture into Melville waters for fun. No pun intended…maybe books on tape?

  22. Now look, why would you not want your authors to go off on tangents or take the time to elaborate extensively on their subject? Remember, you’re reading literature for fun, not because it is a chore. If it’s a chore then get the Cliff Notes. Better yet, just read a one paragraph summary and forget about the rest.

    “Moby Dick: Whale eats whaler’s foot. Whaler chases whale. Many adventures. Ship sunk. Call me Ishmael.”

    “I, Claudius: Roman Emperor. Not really retarded. Intrigue. Conspiracy. Stuttering. Orgies.”

    Come on now.

  23. Gaye–

    I thought Hemingway was brilliant b/c his prose mimicked “good sports column” writing, and thus he enabled all the jocks and rocks to finally open a book and read with pleasure–just as Harry Potter has become a gateway for the kiddies.

    As for Melville–get Moby-Dick on CD or tape, the one narrated by Frank Muller as his voice absolutely brings the narrative to life. Otherwise, try out Melville’s “Benito Cereno”, a more accessible novella.

  24. What surprised the heck out of me was the fact that I could have a perfect spinal xray taken at my PCP showing good alignment and no abnormalities yet have one taken at the chiroprators and it comes out all wonky and twisted. They wanted me to go 3x a week for 3 months. I think they liked my $$$

  25. I always thought chiropoppers were complete quacks, mostly they are.
    I’m 60 with a 20 year history of sciatica. Most of the time I can do leg rolls and get my lower back to pop and stop the sciatica. If I can’t I used to get a $100.00 one hour massage and then I could crack it. Now I pay a Chiropractor $40.00 to crack it for me and it’s done in 15 minutes and I’m out the door.

    Let them treat anything else?
    You gotta be nuts.

  26. For my 3rd yr family practice rotation I
    worked at a private office in a small Alabama town. My patient one morning was a middleaged
    male with an acute lumbar strain. He was quite adamant about which NSAID and muscle relaxant he wanted and that he didn’t need Xrays. Upon presenting him to the attending,I learned my patient was the local chiropractor, who also treated diabetes, hypertension, and depression. He knew what worked for back pain though.

  27. (Chiropractor here.)
    Oh, Lord. It’s dog-pile-on-the-chiro, eh? Sure, everyone knows soemone who was hurt by some wackadoo ‘choirpractor”, or saw a patient who had some bad outcome after seeing a chiropractor (which is not the same thing as it being causal). That doesn’t mean all chiropractors are ham-handed idiots or massage school dropouts. Didn’t they teach you all in medical school about observation bias? And not to piss on your hands in the men’s room?

    Gaye, you’ve got to be kidding me. Infected ulcerations over spinouses from an Activator? Must be the first and only reported case. And you know this how…? Because the patient told you?

    Have you ever seen an adjusting instrument like the Activator? It delivers a spring loaded impulse, and the total contact time with the skin is a fraction of a second. It couldn’t bruise an apple. And while I’m not a huge fan of the technique and really don’t use it much, I can tell you that it is almost never applied directly over a spinous, either. Maybe this, uh, “limited, elderly gentleman” had decubiti? Wouldn’t that be more obvious?

    Sure, it’s fun to bash chiros. I’ll be first to admit we’ve got a lot of loonies out there. But there are also quite a few level headed, knowledgable doctors of chiropractic out there too.

  28. I just came accross this and realize I am reviving an old thread here… but I disagree with your assessment of chiropractic. I would agree that some of the things they claim to treat could be faulty. But I believe they do definitely help treat back and neck pain and some other painful conditions related to the spine. There are scientific articles that back this up and consumers tend to agree. When I have neck and back pain I go see my chiropractor and it works for me.

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