I have noticed while perusing the Sunday edition of the Los Angeles Times that some contemporary chiropractors continue to find inspiration from Bartlett Joshua (B.J.) Palmer (1882–1961). B.J. was the most influential developer and promoter of chiropractic as a business opportunity and ostensibly as a healing profession. He was famous for his salesmanship and the many epigrams he shared in order to inspire Palmer College of Chiropractic students. One of his most famous epigrams was: “Early to bed, early to rise, work like hell and advertise.”
In his Los Angeles Times column on September 14, 2014, David Lazarus wrote about chiropractors “who run newspaper ads with bold claims about breakthrough treatments for diabetes and other chronic illnesses” featuring “invitations to free dinners that are actually sales pitches.” Lazarus quoted Robert Puleo, executive officer of the California Board of Chiropractic Examiners about the ads: “It reeks of snake oil. There are some chiropractors out there who want to make a buck any way they can.” And: “The chiropractor holding such seminars tries to sign people up for months of office visits that can cost thousands of dollars.”
Last February, I wrote an article about free dinner seminars and mailed promotional materials advertised in the Times to promote a chiropractor’s non-validated treatment protocol for peripheral neuropathy. The chain of clinics promoting the protocol does indeed try to convince people to sign contracts for ongoing treatment, charging individual patients thousands of dollars.
Last summer, a half-page color advertisement promoting upcoming “free dinner seminars” at various locations in eastern Los Angeles County and Orange County appeared at least nine Sundays in the main section of the Los Angeles Times. The first and largest printed word in the ads was “ARTHRITIS.”
Each ad also included: a list of symptoms of arthritis; the phrase “New, non-surgical drug free treatment to relieve the pain in your joints;” dates, times, and restaurants for four to six seminars, mostly in Los Angeles County with a few in Inland Empire and Orange County; a paragraph mentioning that there are over 100 types of arthritis with osteoarthritis being the most common type; and this text:
- Could this be the answer to your pain?
- How was your quality of life before your pain started?
What were you able to do that you are limited in doing now?
- It can be that way again.
- If you have any of the symptoms mentioned above, or you’ve been diagnosed with Arthritis [sic] this can be your solution. With our new-state-of-art technology almost everyone with Arthritis [sic] is a candidate for our care.
- If you or a loved one is suffering from these symptoms a new safe, easy and FDA cleared treatment that requires NO surgeries can relieve your pain and help restore normal life.
At the bottom of the ads in large print was a phone number followed by the name i-Spine. Under i-Spine in smaller print was the rest of the name: “Health Center.” Below that in even smaller print, was: “BY AL-SELHI CHIROPRACTIC.”
I suspect that many people who have called the phone number at the bottom of the ads didn’t notice that a chiropractic clinic is promoting the dinner seminars. A similar ad appeared in the Orange County Register on January 3, 2016.
I called an advertising consultant for the Times and was told it would cost $15,750 for a half-page color ad in the Sunday main section for all regions where the print edition of the paper is published, but I could get a better deal per ad if I ran the ad six times. I don’t know whether i-Spine Health Center eventually shifted to advertising at lower cost to only regions including and near i-Spine’s Glendora location. I would not have seen such ads where I receive the Sunday paper.
From what I saw, it’s clear that i-Spine Health Center has needed to generate significant business just to cover advertising expenses and the sales presentation expenses of dinner seminars. I expected that the sales presentations of dinner seminars would lead patients toward signing contracts for ongoing treatment in order for the promotional investments to pay off. I wondered how and what the i-Spine Health Center’s “new-state-of-art technology” could be.
So I called the phone number provided in the advertisements and reserved a seat at a dinner seminar in Burbank. I wound up as one of seventeen dinner guests at that seminar. All except about three of the dinner guests seemed older than me and most seemed much older than my fifty-eight years. I think I stood out among the dinner guests by not being noticeably infirm.
Before the seminar began, I took out my camera phone and held it up to take a picture of the screen set up at one side of the seminar dining room. The screen displayed a title slide image for the upcoming presentation. Dr. Al-Sehi entered the room and saw what I was doing. He asked me not to take any photos. I obliged and then I wrote in my notebook what appeared on the title slide:
- I-Spine Health Center
- DR FADI AL-SELHI, D.C.*
- RANCHO CUCAMONGA, CA [apparently the clinic’s former location]
A few minutes later Dr. Al-Sehi began the seminar. I took notes. While reviewing them afterwards, I saw the seminar as consisting of four phases: (1) building trust, (2) medicine bashing, (3) Dr. Al-Selhi’s alternative, and (4) recommending consultations.
Phase 1: Building Trust
Dr. Al-Selhi introduced himself. He mentioned that he’s married and has a young son. He discussed his educational background, which is mentioned on his biography page at his clinic’s website:
Dr. Al-Selhi obtained his Doctorate of Chiropractic Degree [sic] from Cleveland Chiropractic College, Los Angeles [which closed in 2011]. Prior to obtaining his chiropractic degree, he graduated from California State Polytechnic University, Pomona, with a Bachelor’s Degree in Biology.
He also mentioned at the seminar that he had enrolled in the master’s in gerontology program at University of La Verne (California). Apparently, he didn’t finish the program.
I thought he presented himself as sincere and caring during his introduction and throughout the seminar. I imagine that some dinner guests might be much more impressed with his educational background than I was. Nevertheless, I thought Dr. Al-Selhi succeeded in connecting with his audience and used an effective propaganda device described by social psychologist Anthony Pratkanis in the July/August 1995 issue of Skeptical Inquirer: manufacture source credibility and sincerity.
Phase 2: Medicine Bashing
Medicine bashing is a well-established tradition within chiropractic. B.J. Palmer’s popular epigrams include:
- Medicine is the study of disease and what causes a man to die. Chiropractic is the study of health and what causes a man to live.
- Medicine is about disease and what makes people die. Chiropractic is about life and what makes people live.
After introducing himself, Dr. Al-Selhi shifted to a discussion of the inefficiency and poor quality of the U.S. health system. He referred to a report from the Commonwealth Fund that ranked the U.S. health system last among eleven countries. He didn’t mention that the report called for greater investment in primary care (not care from chiropractors), identified insurance administration as a main source of inefficiency (not deficiencies of modern medical practice), and noted that the United States actually ranks high in two of four measures of quality: effective care and patient centered care.
Dr. Al-Selhi suggested that a problem in the field of medicine is that it tries to provide a pill for everything. He mentioned that ibuprofen (active ingredient in Motrin and Advil) causes kidney damage in diabetics (which is a real risk with regular use). He talked about acetaminophen (the active ingredient in Tylenol and known as paracetamol in the UK) as a treatment for the pain of osteoarthritis—the most common type of arthritis—and recognition that excessive doses of acetaminophen can cause potentially fatal liver damage.
As noted by Harriet Hall, MD, the potential for benefit and harm from acetaminophen in osteoarthritis treatment have been much discussed and debated in recent years, and medical doctors encourage patients to try alternatives to pill-taking such as distraction, comfort measures, exercise, and massage.
Dr. Al-Selhi conceded that pills for hypertension are okay, but then asked rhetorically: “Are pain medications addressing the cause or are they masking pain?” He later asked: “Are any drugs addressing the cause of the problem?”
He said that referrals for pain management lead to more pills that don’t address the cause. He highlighted problems of cortisone shots that wear off. He talked about knee replacement surgeries not addressing the cause. He said that 75 percent of low back-pain surgeries fail (without citing a source).
He mocked doctors who say things like:
- “This is a normal part of aging.”
- “You’re just going to have to live with this.”
- “Sorry, nothing can be done at this point.”
He presented a famous quotation that goes something like: “The definition of insanity is doing the same thing over and over again, but expecting different results” and made the common factual error of misattributing it to Einstein. I guess that misattributing pithy quotations to Einstein enhances rather than undermines the bottom line effectiveness of sales presentations.
Chiropractors often present themselves as addressing the underlying cause or causes of health problems while suggesting that medical doctors only treat symptoms. B.J. Palmer said:
- There is no effect without a cause. Chiropractors adjust causes. Others treat effects.
So what did Al-Selhi reveal to be the cause that supposedly eludes medical doctors? Nothing but inflammation. This assertion was especially puzzling since his talk emphasized osteoarthritis, which, may involve various degrees of inflammation of joint linings, but is not significantly caused by inflammation. According to MedlinePlus:
Osteoarthritis is the most common form of arthritis and is associated with the aging process. Osteoarthritis is a chronic disease causing the deterioration of the cartilage within a joint.
For most people, the cause of osteoarthritis is unknown, but metabolic, genetic, chemical, and mechanical factors play a role in its development.
Phase 3: Dr. Al-Selhi’s Alternative
Dr. Al-Selhi claimed to be able to address inflammation with laser energy to increase circulation, thereby drawing water, oxygen, and nutrients to the damaged area. I wrote in my notes that he claimed that Nexus therapy providing a red light at 980 nanometer (nm) wavelength [actually within the infrared range] is used to penetrate nine inches deep to accelerate cellular reproduction and growth. [Nine inches?] He talked about accelerating angiogenesis (development of new blood vessels), causing vasodilation, and increasing the diameter of blood vessels. He showed a figure of a joint with and without laser therapy that he said indicated more blood vessels with the laser therapy.
He said the treatment is FDA cleared, as stated in his Los Angeles Times ad, and proven to relieve arthritis pain. He said that drugs are approved by FDA, but equipment is cleared. Actually, some types of medical devices are also approved by FDA, but manufacturers can get what is called a 510(k) clearance for marketing by demonstrating that the device to be marketed is at least as safe and effective, that is substantially equivalent, to a legally marketed in the United States.
The 510(k) clearance summary for Nexus devices that “deliver an invisible laser light beam in the infrared spectrum at wavelengths of 805 and 980 nm” indicate that the devices are substantially equivalent to other infrared therapeutic lamps currently in commercial distribution. The summary includes these indications for use:
- The Nexus XPulse IR Lamp Systems are intended to emit energy in the visible and infrared spectrum to provide topical heating for the purpose of elevating tissue temperature for the temporary relief of minor muscle and joint pain and stiffness, minor arthritis pain, or muscle spasm; the temporary increase in local blood circulation; and/or the temporary relaxation of muscle.
Providing temporary relief or physiological changes seems more like treating effects than some cause that chiropractors claim they, unlike medical doctors, can address.
Dr. Al-Selhi said there have been over 6,000 published papers on laser therapy. But he didn’t say how many of them actually support laser therapy as an arthritis treatment and, in particular, osteoarthritis, the form of arthritis he emphasized in his seminar.
Arthritis Research UK had this to say about low-intensity laser therapy for osteoarthritis in Spring 2008:
It appears safe enough. However, the clinical trials in osteoarthritis to date haven’t been very encouraging. In fact, a meta-analysis (where the results of all the trials are pooled together) showed only mild beneﬁt for pain and no beneﬁt for stiffness or function. How does it work? Well, it probably doesn’t, but users of this treatment say that the light penetrates and interacts with the deeper tissues of the body.
According to the health insurer Aetna, treatment of osteoarthritis with low-level infrared light is experimental and investigational because evidence regarding its effectiveness is insufficient. Cigna has a similar medical coverage policy statement for low-level laser therapy. Insurers don’t cover treatments that are experimental or investigational rather than validated as safe and effective.
Also according to Aetna:
Recent well-designed, controlled studies have found no benefit from low-energy lasers in relieving pain in rheumatoid arthritis or other musculoskeletal conditions. Furthermore, although positive effects were found in some earlier studies, it was not clear that the pain relief achieved was large enough to have either clinical significance or to replace conventional therapies.
Phase 4: Recommending Consultations
Dr. Al-Selhi recommended that people with arthritis arrange for consultations with him. He explained that the first consultation would involve paperwork (of an unspecified nature), taking a health history, an exam, and x-rays (if not taken within the last six months). The second consultation would involve the report of findings. He described that consultation as a “family affair” so family members can understand what you’re going through.
An inquiring mind might wonder why the report of findings could not be given as part of the first consultation. A busy medical practice can still manage to provide a report of findings at the end of a single visit following the taking of the health history, the exam, and x-rays.
Dr. Al-Selhi didn’t say why a second consultation was required for the report of findings, but having patients come back for a report of findings is consistent with teachings of practice-building courses promoted to chiropractors to teach them how to increase their income through marketing techniques, efficient office management, rehearsed selling strategies, and billing practices. In Chiropractic: The Victim’s Perspective (Prometheus Books, 1995), George Magner wrote:
The ICA [International Chiropractors Association] Practice Manual states that the goal of the second visit (report of findings) is to convert the new patient into a “chiropractic patient.” [p. 73]
Magner quoted Frank J. King, Jr., a chiropractor who is also a naturopath and founder/director of the homeopathic products company King Bio Pharmaceuticals who, in an article in The Chiropractic Journal, likened initial patient contacts as a courtship:
The examination can be compared to the engagement, and the report of findings to the wedding or final ceremonial. If the correct emphasis is placed on a thorough history and the appropriate examination and lab tests, then the report of findings simply falls into place like a smooth wedding ceremony. All the tension of the doctor and the patient is eliminated, and there is no need to attempt a “ldquo;sales job” on the patient.
Magner also quoted Mitchell W. Hanczaryk, D.C., a promoter of practice building, as advising chiropractors to:
…get patients committed to a next appointment time. Either the next day, week, month, or whatever they need…. The only active patients you have are the ones with an appointment in the book. If you allow a patient to leave the clinic without an appointment, you are cheating them and killing them.
It is likely easier to get patients to come back for the report of findings following the first appointment than it is to immediately get them to contract for repeated visits. In the aforementioned Skeptical Inquirer article, Professor Pratkanis discussed the foot-in-the-door persuasion technique in which the persuader starts with a small request, which sets a rationalization trap that facilitates commitment to a subsequent larger request.
Samuel Homola, D.C., a retired chiropractor and outspoken critic of cultism in chiropractic whose writings have appeared in Skeptical Inquirer had this to say about the report of findings as a “family affair”:
There is no legitimate reason why a spouse should be present for “report of findings” or a discussion of “cost-effective treatment plans.” Such an approach is usually a sales pitch used to indoctrinate both husband and wife into accepting enrollment in a long-term treatment plan.
Dr. Al-Selhi said the price for the two consultations was $249, but it would cost seminar attendees $79 for the two consultations. His pitch reminded me of a similar approach to marking down prices routinely taken in television infomercial pitches. I was amused when he then advised dinner guests, rather gratuitously, not to come for the consultations if they came to the seminar just for the free dinner.
Neither the consultations nor any laser treatment are covered by insurance. Thus, during the seminar, Dr. Al-Selhi raised this rhetorical question:
- What has your health insurance covered that works so great?
The fallacious implication, of course, was that paying out-of-pocket is likely to be worth a try.
After the seminar, it was dinnertime. Dr. Al-Selhi came to talk individually with each of his guests including me. He asked me if I came just for the free dinner. I thought he might be wary of me from the very beginning of the seminar. I wondered if he suspected that I was investigating him in some official or unofficial capacity.
I responded truthfully that I had surgery on my right knee in 2002 for a torn meniscus, that my knee sometimes bothers me after I play basketball, and that, as he pointed out during the seminar, arthritis can develop years after meniscus surgery. I was a bit surprised that, after all his talk about treating the cause of arthritis with his laser, he recommended that I see a physical therapist to strengthen my knee rather than seek an initial consultation from him. I believe that was a sound recommendation (and one that would be covered by my insurance). However, other guests were encouraged to make appointments for consultations.
Dr. Al-Selhi announced during dinner that he had to leave early for an appointment. When he left, two of his clinic staff who were with him stayed on through dessert. I spoke to one of them who explained that the consultation could be marked down more than Dr. Al-Selhi had announced. “We can get you in next week for $29.00,” she said.
I asked the other staff member how many visits is typical for the laser treatment. Her answer was twenty-four. I also asked how much it would cost. Her response was that Dr. Al-Selhi sets that price.
Some Final Thoughts
Many people with arthritis are likely to be persuaded by various social influence techniques included in sales pitches for non-evidence-based treatments.
In a national survey conducted in 1986 by Louis Harris and Associates for the U.S. Department of Health and Human Services, 18 percent of persons with arthritis said they almost always had a significant amount of pain and 22 percent said their conditions caused significant pain frequently [p. 202]. Thirty-seven percent of persons with arthritis strongly or somewhat disagreed and 8 percent were unsure in response to the statement: “most arthritis treatments you read about are not believable” [p. 187].Thirty-four percent strongly or somewhat agreed with: “I am willing to try anything that might help my condition even if it sounds silly” [p. 203].
I’m not aware of any more recent relevant data. It would surprise me if people with arthritis have become appreciably less inclined to gamble their money on aberrant treatments.
Many of Dr. Al-Selhi’s patients are likely to be satisfied customers even if his treatments are no more effective than sham laser treatment or low-tech warming treatments. As with many chronic diseases, major forms of arthritis are subject to spontaneously flaring up and subsiding over varying periods of time. When a treatment is given right before a period of spontaneous relief, patients may overlook the natural course of the disease and erroneously conclude that treatment was effective.
When people invest significant amounts of time and money in an endeavor (perhaps such as committing in advance to a long-term treatment plan with a chiropractor), they tend to attribute greater value than is objectively warranted to the outcomes they receive. Psychologists attribute this phenomenon to mechanisms such as effort justification or psychological contrast effects.
While the effectiveness of low-level laser treatment of arthritis conditions has not been conclusively demonstrated, I don’t rule out the possibility that it can provide some degree of symptomatic relief for some patients under some circumstances. But even that falls far short of the hype in the ads for the seminars and the cause-treating hype I heard at the seminar. And that doesn’t mean the treatment is worth whatever patients are asked to pay out of pocket.
I suspect that many patients who commit to a series of ongoing laser treatments for arthritis are likely to experience buyer’s remorse. Consumer advocate Stephen Barrett, MD advises consumers not to pay or contract in advance for chiropractic visits at what gets represented as a “discount” price.
I looked up Dr. Al-Selhi in the database of the California Board of Chiropractic Examiners and found that there have been no disciplinary actions against him—not even the kind of minor actions that the Board has taken against other chiropractors for misleading advertising.
I encourage dissatisfied patients of chiropractors to complain to their state’s chiropractic examining board if they believe they were misled by advertising claims by chiropractors or regret signing a contract in advance of chiropractic visits. I’m not sure how much of a difference submitting complaints about advertising claims can make. However, as B.J. Palmer liked to say: “It is better to light one candle than curse the darkness.”
* What is it that leads many chiropractors to redundantly write “Dr.” before their names when they also include an abbreviation of their Doctor of Chiropractic after their names? The only time I can recall seeing such a construction from a non-chiropractor with a doctoral degree was in the credits of The Cosby Show, which listed “Dr. William H. Cosby, Jr. Ed.D.” There are reasons for doubt about the rigor of Dr. Cosby’s doctoral training.