PRESIDING CHAIRMEN: Senator Handley
COMMITTEE MEMBERS PRESENT:
SENATORS: Slossberg, Roraback, Coleman, Fasano, Stillman
REPRESENTATIVES: Ritter, Carson , Ayala, Bye, Christiano, Fahrbach, Giegler, Heinrich, Hetherington, Hurlburt, Klarides, Malone, Nardello, O' Brien, Olson, Panaroni, Ryan, Scribner, Wasserman, Widlitz
SENATOR HANDLEY: Good morning, I' ll call to order the March 5 th public hearing of the Public Health Committee. What we will do is common, we will start with the Legislators, agencies, and other officials speaking for the first hour, so by 11:15 a.m. we will be moving to the public.
We have been asking the folks in the public domain to keep their presentation to be very brief, to do it in the three minutes that we' ve asked the public in the interest of getting our public hearing done.
There is always, of course, opportunities for the Committee to ask questions, but we will ask folks to make their presentations as brief as possible.
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SEN. HANDLEY: Thank you very much. Are there questions? Thank you. We will now move to Senate Bill 1252. Our first speaker is Britt House, Harse? Followed by Janet Levy.
Britt, I'll ask you to just sit, just wait for a minute, for the folks who are leaving, so your testimony won't be disrupted by the doors, coming and going. I think you can begin now.
BRITT HARWE: Okay. Good evening, Senator Handley, Representative Sayers, and distinguished Members of the Public Health Committee. My name is Brittany Harwe. I am testifying in support of Senate Bill 1252.
I would like to advise the Committee that I have a paralyzed vocal cord, so please bear with me. In 1993, when I was just 26-years-old, I had a stroke, immediately, following a chiropractic adjustment.
I was taken by ambulance to the hospital and tests revealed that my left vertebral artery was crushed. I was diagnosed with Wallenberg's syndrome, a neurological disorder which among other disabilities includes left side paralysis, paralyzed vocal cord, and the loss of the ability to swallow.
During the first few weeks in the hospital, my prognosis was uncertain. It was unknown if I would ever walk or talk normally, again. There was even discussion about putting me in a nursing home. Since I couldn't swallow, a feeding tube was inserted.
For the past 14 years, I've been unable to eat normally and I will have this feeding tube for the rest of my life. There is no doubt that the risk of stroke exists, unfortunately, I and many others like me are proof of this. Chiropractors, themselves, in their own literature, have admitted to the risks.
In fact the Palmer Institute for Professional Chiropractic Advancement, actually, offers a course in avoiding malpractice in chiropractic for stroke. To add insult to injury, hundreds of victims have been silenced by personal, permanent disabilities, or by gag orders. So the actual number of victims is unknown.
In a January 2007, letter, the President of the American Chiropractic Association writes, the chance that a chiropractic manipulation will result in a serious reaction in an adult patient is remote, ranging from 1 in 1 million, to 1 in 5.85 million manipulations.
But the International Chiropractic Association states, chiropractic adjustment is a safe efficient procedure which is performed nearly one million times, every working day in the United States . This means they acknowledge that hundreds of people are seriously and needlessly injured every year. The American--
SEN. HANDLEY: I will ask you to summarize, if you would, please.
BRITT HARWE: All right. Complete informed consent means not only written, but more importantly, a reasonable discussion of risks, a discussion using the word stroke, which is clearly understood to result in grave injury, as opposed to using the word reaction, which does not sound nearly as serious.
With this information, a patient will have the opportunity to consider the benefits versus risks of treatment. If patients are made aware of this risk of stroke, the symptoms of stroke would be recognized and immediate emergency medical care could be sought.
I printed all my supporting documentation and thank you for giving me this opportunity to express my concerns.
SEN. HANDLEY: Thank you for your willingness to be here. Are there questions? Senator Fasano.
SEN. FASANO: Thank you, Madam Chair, and I will try to keep the questions just really brief, and perhaps, Britt can answer, fairly, quickly, because we are getting late in the hour.
Now with respect to the issue of manipulation, there has been a sense that this bill is anti-Chiropractic bill. Would that be an unfair statement?
BRITT HARWE: Yes. I believe it's unfair. I'm not anti-chiropractic. I know many people have benefited from chiropractic and swear by the treatment.
All we're asking for with this bill is to give people the information that the chiropractic community and the medical community has known for years.
SEN. FASANO: And with respect to that, so we're just talking about the manipulation of the neck, forgetting about the other issues with respect, you know, chiropractic does all body. But your issue is with the neck, is that fair to say, that the limited issue here is the neck?
BRITT HARWE: There have been injuries with other types of adjustments, but the adjustment with the neck results in serious injury, stroke or death.
SEN. FASANO: And had you had the informed consent, that is to stay, if we manipulate the neck there is a chance, albeit slight or whatever, of a risk of stroke, what if anything that would have done to your decision?
BRITT HARWE: When I asked my chiropractor before the adjustment, the only risk he told me was of a reaction. Now I took that to mean as a minor thing.
So if the word stroke is used, that's understood as being grave, and that way if the person walks in with a hurt shoulder, I had a pinched nerve, to take the risk of stroke in order to relieve some possibly minor ache or pain, I wouldn't take that risk.
SEN. FASANO: And then just a last question, you eat through a feeding tube inserted through your stomach now, is that correct?
BRITT HARWE: Yes.
SEN. FASANO: You still do?
BRITT HARWE: Still do.
SEN. FASANO: Thank you. Thank you, Madam Chair.
SEN. HANDLEY: Representative Sayers.
REP. SAYERS: Thank you. Excuse me.
SEN. HANDLEY: Please stay, Britt, we've got a couple more questions.
REP. SAYERS: Patient's rights indicate that informed consent is already part of patient's rights', do you feel that the Chiropractor that you saw misrepresented you or provided treatment in such a manner that it was, probably, detrimental?
BRITT HARWE: Chiropractic is the only medical profession that I know of that is advertised as safe and natural. So this puts people at ease, thinking there could be no risks and when discussed, it was just a reaction. So I didn't think there was any serious risk to be taken.
REP. SAYERS: But following that, did you feel like that there was a problem?
BRITT HARWE: Once I realized that they had known about this and written about this in medical literature for decades, yes.
REP. SAYERS: Did you make a complaint to the Health Department?
BRITT HARWE: I was discouraged by my attorney when I pursued legal action. He did not want me to file a complaint. Then afterwards it was almost five years later, and it was intimidating, the amount of information that was requested by the Department of Public Health.
REP. SAYERS: And, actually, they need that information, in order to--
BRITT HARWE: Yes. They wanted all the past--
REP. SAYERS: To make and follow-up and do a thorough investigation.
BRITT HARWE: Absolutely. I understand, they wanted five years of every time I had seen a doctor, and since my stroke, I see doctors all the time. So in order to get every single record, for a total of five years, was too much.
And what happens with a lot of other stroke victims that I have talked to, their settlements require them to sign a gag order. The gag order, specifically, states that they cannot cooperate with any state, federal agency, including the Department of Health.
So that is why you don't see many complaints at all to the Department of Public Health.
SEN. HANDLEY: Representative Giegler.
REP. GIEGLER: Thank you for coming before us, today. I understand the difficulties that you've undergone, having seen a chiropractor, and you said that you don't feel that this bill is directed just at Chiropractors'.
However, state statute does not mandate any kind of written informed consent. And last year, we had before us a bill that would allow manipulations and things to be done just by physical therapists, who have less of an education than chiropractors do.
What I want to ask you is, I mean, your situation is very unfortunate, but don't you feel that there is other disciplines like MDs, DPMs, other, kind of, allied health professions that there can be certain individuals that go to see them that have adverse effects happen and it could be that it could be based on just the chiropractor that you choose, unfortunately, to see, rather than it being the whole profession, itself?
BRITT HARWE: After speaking with so many victims, it is not an isolated event. They do admit that it could happen, as much as one in one million.
They do a million adjustments a day. Medical doctors go to medical school. They do residency in hospitals. They're taught in school to give complete informed consent.
They're required by hospitals to give complete informed consent, and by their organizations, such as the AMA.
Chiropractors do not go to medical school, do not have hospital privileges, and do not have one organization to get guiding principles from, like, the majority of doctors do. So that's why I think it is important that the state step in and mandate this.
REP. GIEGLER: Well one of the issues is that, and has been before us, too, was in the instance of medical malpractice and a lot of medical malpractice rates are based on the risk factors that are involved with those professions.
Now chiropractic medical malpractice rates are very low, you know, they're like $2,700 a year. Based on that, you know, they can't have a lot of instances of situations, like yours.
Otherwise, they would be as high as the neurologists and some of the other ones, so how do you answer that?
BRITT HARWE: You need to remember, medical doctors treat very ill and fragile patients with surgery and invasive procedures. Chiropractors, generally, deal with a healthy population and don't do any invasive procedures.
When you are going to a doctor, and having open heart surgery, you are well aware that there is going to be a risk, and those risks are gone over with you. When you go into a chiropractor with a sore shoulder, you are not expecting to take any life threatening risks.
And as far as their malpractice being lower, again, they treat a health population. Also, when I asked my chiropractor, before he did the adjustment, if there was anything, he said a reaction. Now my stroke, where the artery was crushed, happened immediately.
The majority of these strokes, a tear in the artery wall happens. Your body immediately tries to heal itself. It's called a TIA, like a mini stroke, so the person can, actually, walk out of the chiropractor's office and it might not be until, like a weak, or two later, that the clot bursts and shoots up into the brain, causing a stroke.
And at that point, it is not related back to the chiropractic adjustment, because no one has heard about this. But it does happen, and if it's not related back to the chiropractic adjustment, there is no malpractice claim put in, so therefore, there is nothing paid out and the rates remain low.
REP. GIEGLER: Thank you very much for your input.
SEN. HANDLEY: Thank you very much for your testimony. Our next speaker is Janet Levy, followed by Matthew Pagano. Good evening.
JANET LEVY: Good evening, Senator Handley, Representative Sayers, and distinguished Members of the Public Health Committee. My name is Janet Levy. I'm here to ask your support for Senate Bill 1252.
Five years ago, I went to a chiropractor, after what he told me was a simple and safe adjustment, he tore the left artery in my neck. I ended up having a stroke and emergency brain surgery to remove the blood clot in my brain.
I was told that I would, probably, never be able to walk again, normally, and certainly, not without the use of a quad cane. Back at home, my husband hired multiple therapists, and expensive exercise equipment, and beyond the three months that the insurance helped me pay for, he paid for.
And then he also hired somebody to help me dress and bathe. After, almost, two years of spending nearly seven hours every, single day for therapy, I got my life back to where you see it, today.
During this time and, certainly, for months afterwards, I found out what happened to me was not an isolated incident.
There appeared to be tons of literature about it, articles, studies on the Internet, directly relating the incident of stroke to chiropractic adjustments. Not only here in the United States , but in ten other countries.
I also found that there were a number of support and informative groups around the country that consisted of hundreds of victims, who are suffering from the effects of manipulation or who had died from one.
I never, ever, knew that a chiropractic manipulation could cause a stroke or even the risk of one. The only thing I ever read about them was that they were safe and natural.
Being that chiropractic adjustments could have serious risks, like, stroke, permanent disability, even death, no matter how rare chiropractors feel it is, it must be the patient's right to be informed of all risks, so that they can could decide for themselves, whether a certain procedure is worth the risk or not.
In Senate Bill 1252, we are asking for complete informed consent, which is more than simply getting a patient to sign a written consent form.
It is the process of communication between a patient and physician that results in the patient's agreement to undergo a specific procedure. All risks and benefits of a proposed treatment are fully explained to the patient.
Medical doctors give complete informed consent. It is part of their medical ethics. The medical schools, hospital training, as well as the organizations, such as the AMA have told them that they must give informed consent with any and all medical procedures.
Chiropractors, however, do not go to medical schools, they don't have hospital training, nor do they agree on one major chiropractic organization to give them universal guidelines. Yet, chiropractors are allowed to, by law, to refer to themselves as physicians.
So the public automatically assumes that they practice the same standards as medical physicians, and, unfortunately, like, my self, many people in Connecticut are not aware that chiropractors are not medical physicians.
It is highly prejudicial that chiropractors do not have to adhere to the same regulations as real physicians, yet they are able to refer to themselves as physicians.
SEN. HANDLEY: Will you summarize the rest of your statement, please?
JANET LEVY: Yes. I would like to add that chiropractors advertise that chiropractic is a safe, natural alternative. It is an irresponsible statement to make considering its life threatening risks.
Informed consent would have saved my life and would have saved two years of a harrowing experience. I know hundreds of young victims who have contacted the Chiropractic Stroke Victims Awareness Group over the years, would appreciate an answer to this, and want to know, why we don't know the risks. Thank you very much.
SEN. HANDLEY: Thank you very much for your testimony. Senator Fasano.
SEN. FASANO: Thank you, Madam Chair. I think it was Representative Sayers, Chairwoman Sayers, had asked about filing a complaint with the Department of Public Health. Did you file a complaint with the Department of Public Health?
JANET LEVY: No. I did not.
SEN. FASANO: And can you explain why you did not file a complaint with the Department of Public Health?
JANET LEVY: Well, at the beginning of every case, you're told not to file, because you won't win your lawsuit if you do. And then afterwards, the people who settle, have us sign a gag order that says you cannot go to the Department of Public Health and lodge a complaint with them or anybody else.
In fact, they wanted me to sign a standard form that they give in Connecticut , and I refused to sign it, so I had to get another attorney against my attorney, to make sure that I didn't get to sign that one, because that's what everyone has gotten to sign.
If you don't have the money or the resources, you can't fight that. And so you end up signing something that you can't say the name, you can't say that you went to a chiropractor, you can't say the amount, you can't say what happened, where it happened, anything.
SEN. FASANO: And with respect to your issue, what you're saying is that when you settled the claim, you had to, one, agree not to make a complaint to public health, is that right?
JANET LEVY: Correct.
SEN. FASANO: That is what they asked you to do?
JANET LEVY: Correct.
SEN. FASANO: Number two, that you would not make any voluntary statements to any agency or any person with respect to any issues that you had with respect to your condition, is that right?
JANET LEVY: That was the first standard gag order that they wanted me to sign, which I did not sign and refused to sign.
SEN. FASANO: And that this would prohibit the state to collect any information that they may need to determine whether or not, what the ratio of incidences are, certainly, somebody has to make a complaint to the Department of Public Health.
JANET LEVY: There would be no way for anybody to find out if there were any complaints or not.
SEN. FASANO: This is the mechanism the state has chosen to log in these issues, but if you're not able to do that, that information would not get to the state, is that fair to say?
JANET LEVY: Correct.
SEN. FASANO: Thank you, Janet, thank you for coming up. Thank you, Madam Chair.
SEN. HANDLEY: Thank you. Thank you for being here.
JANET LEVY: Thank you very much. Oh. One more minute, Janet.
REP. GIEGLER: Thank you for coming before us, today, just to follow-up on Senator Fasano's questioning, about filing with Department of Public Health but the chiropractors also have a Chiropractic Board of Examiners, that looks into disciplinary action on any chiropractors. Did anyone ever file a complaint with them?
In the Chiropractor Stroke Victims Awareness Group there are hundreds of victims in Connecticut , I think we've looked up every chiropractor, there is not one that says disciplinary action.
It says disciplinary action and it says, none, next to it. There is not one of them that has anything that shows up, anywhere.
REP. GIEGLER: Do you think that that's a result of people being unaware that this Board exists and they can file a complaint against them, or do you think it might be as many claims against them as one might think?
JANET LEVY: Well, the Department of Health keeps a physician's profile and on it, you know, you go to ct.gov, you go and you can find the Department of Health, and you can easily find out the education of a medical doctor, his training, if he had any malpractice lawsuits or settlements.
It doesn't give the amounts but it will say if it was average, above average, below average. When you go to the same thing for chiropractors, it just gives his license number and disciplinary action, and like, I said, it always says none, unless there's something else not related to health--
REP. GIEGLER: I think, the Department of Public Health that is the only group that they, actually, keep track of, and if you go online and you see the number of licensures, that they are responsible for, I don't think those disciplines are listed under the website, so you can get--
JANET LEVY: No. There was a law that was mandated for all licensed physicians--
REP. GIEGLER: Just physicians.
JANET LEVY: --in Connecticut, which is a misnomer because everybody thinks they're physicians, so by law, they are allowed to say that they are physicians, so if in Connecticut they have a law that says all licensed physicians must do this, people get confused, I know.
REP. GIEGLER: Well, nowadays, you're also looking at PhD's in psychology, you know, when you work in psychiatry, we call them doctor, but they're really PhD's in psychology, so its--
JANET LEVY: Physicians. Right.
REP. GIEGLER: This is an expanded issue with a number of people that a PhD that we call them doctor.
JANET LEVY: They are supposed to identify themselves by state statute and say that they are doctors, I mean, chiropractors, when they call themselves doctor.
REP. GIEGLER: I know, from being to a chiropractor, my self, that when you go into their offices and they have their licenses up on the wall, just like any other doctor does, that you would see that they are not medical, and they've not graduated from medical school.
JANET LEVY: I don't know of any person that reads all of the licenses--
REP. GIEGLER: I do.
JANET LEVY: --in an office. I do now, I do now, and so do these other people, but it's too late for them. But you're right. It's something that somebody should be taught to do--
REP. GIEGLER: Well, I think, it's important when you go to any healing art, or rather--
JANET LEVY: --find out their education and everything, that's why it should be public knowledge.
REP. GIEGLER: I'm glad that you're doing so well now.
JANET LEVY: Thank you.
REP. GIEGLER: Thanks for coming.
SEN. HANDLEY: Senator Roraback. Miss Levy, one more.
SEN. RORABACK: Thank you, Madam Chair. I was just curious, what, would you think, if we passed a law that said there had to be informed consent. There are risks if I go to the dentist.
There are risks. If I go and see a surgeon, certainly, there are risks. So what if we passed a law that said there ought to be informed consent anytime we access a healthcare practitioner whose livelihood entails potential risks to the beneficiary of the service. Would you be--
JANET LEVY: I think any profession, whatsoever, if they have risks, they should tell you. They should, absolutely, tell you. People are concerned about home building improvement, of contractors, their license, they have to have their license number and an ad, I mean it's very strict.
If this is for your physical well-being, yeah, every risk should be told, every risk that could, possibly be told. And surgeons, they do tell you. I mean, lets face it, we know that if we go bungee jumping or you go in an airplane, or you smoke, you're alerted about the risks.
If you don't wear a helmet for a bicycle ride, you know that there's a risk, that you might die that you might have a concussion, and seriously, hurt yourself. So we are aware of the risks, of not wearing a seatbelt. You know, we are aware.
SEN. RORABACK: I guess I just think when I go to the dentist, I don't remember my dentist ever having warned me of anything, when he gives me Novocain or anything.
Well, they say it' s going to hurt. No. Actually, he says it's not going to hurt, and then, that's another problem. I appreciate the answers.
JANET LEVY: That should be our right to know of any and all risks.
SEN. HANDLEY: Thank you very much.
SEN. RORABACK: Thank you.
SEN. HANDLEY: Senator Fasano has another.
SEN. FASANO: I apologize, Madam Chair. Just because the release issue goes back to the issue of why the state and why even the Chiropractic board may not know, because it says, its recognized that the settlement terms may be reported to the National Databank in accordance with law of Connecticut.
I and counsel agree not to disclose any information to the press, media, verdict reporting services, trial lawyers association, any other individual agencies or organizations, whatsoever. So what that speaks to is that is part of the agreement that they are forced to sign.
Now each individual's will be different. Janet was in a position to say, that's not acceptable to me, as a settlement. I refuse to have that in my terms, and the other side, eventually, backed off. But that is not, necessarily, the case in most of those cases.
So when you say, why isn't it reported, how come we don't know, where's the information, you couple that, with the malpractice bill that excludes that profession, there is no way.
And to attract that type of issue, and I think, what we're talking about, as Senator Roraback's issue, is we're not talking about yanking a tooth or Novocain, we're talking about manipulations of the neck, the spinal cord and nerve center, the actual area that is deemed critical.
So we're talking about something that should not be looked at like taking a sliver out of a nail or of a hand.
And I think that Janet and Britt went through a lot and they're trying to express the fact that chiropractic does have a place, and many people are benefited, and they do great work, and they are very conscientious, at least, the one's I know.
And they are very conscientious and they work hard, and I know, a lot of them are in this room, tonight, to speak about this bill. But on the other hand, there is an issue that says when it comes to the limited area of the neck, that, limited area, perhaps, maybe, there should be some disclosure.
And the disclosure need not be you're going to die, disclosure may not be you're not going to walk again, it needs to say there is an element of risk, slender as all get out, but a risk, and you can proceed from here.
I don't see the onus of the issue, but, clearly, chiropractors, I think ought to only do that on their own accord, what we are saying, perhaps, because the chiropractor agency, as I understand it, is two different groups.
Maybe, one thing that solidifies them is this rule as a statute, and I think, that is the main intent of this bill, is it not, Janet Levy? Thank you. And thank you, Madam Chair.
SEN. HANDLEY: And thank you for being here.
JANET LEVY: Thank you.
SEN. HANDLEY: Our next speaker is Matthew Pagano, followed by Susan Todd-Scott.
MATTHEW PAGANO: Good evening, Senator. Representative Sayers, Members of the Committee, my name is Matt Pagano. I'm a practicing chiropractor in Winsted , Connecticut and I also served as the President of the Connecticut Chiropractic Association.
And I am testifying on their behalf, tonight, in opposition to Senate Bill 1252. I would like to pause, and recognize Ms. Harwe and Ms. Levy and express my sympathy for what they have had to deal with and my sincere wish that they never had to deal with what they've expressed, tonight.
I would say that we oppose this bill, because there is an inference that the practice of chiropractic, specifically, the application of a cervical, or a neck, adjustment, is inherently, high risk. It is not.
The incidence rate is one in three million to one in five million, depending on the literature you read, that's patient interactions. Somewhat apropos to the issue, on the MSNBC.com website, yesterday, was an article that discussed laparoscopic gall bladder surgery in the United States .
Three-quarters of a million of those are performed, annually, and they deem it low risk, and yet 7,500 people a year die, as a result of complications of that procedure. Other things that might help someone deal with symptoms for which a neck adjustment might be applied, somebody could, conceivably, use non-steroidal anti-inflammatories.
If you use a non-steroidal anti-inflammatory for greater than three consecutive months, 400 people die from gastrointestinal bleed out of a million. I offer these statistics, because I want to illustrate the fact that this intervention is, in fact, low risk.
I think, the fact that we pay low malpractice insurance premiums is a valid point. I think the professions claim history is directly proportional to a professions malpractice rates.
As has already been discussed, the performance of manipulation of the neck is not exclusive to chiropractic, MD's, Naturopaths, Osteopaths, and non-physician providers, like, physical therapists perform neck manipulation.
I would sum up by saying that we do not impose the concept of written informed consent. But if any profession, in any procedure, has a level of risk, greater than what the literature supports for chiropractic manipulation of the neck, we think, that informed consent should be mandated across the board, if we're contemplating mandating it, at all.
SEN. HANDLEY: Thank you very much. Are there questions?
REP. GIEGLER: Thank you very much. Thank you for waiting so long, today, to come before us. I just have one question, previous testimony stated that you, as Chiropractors, work with a primarily healthy population, to my knowledge, I've known of situations where going to a Chiropractor has, actually, prevented people from having to have any kind of invasive surgery.
I say that, because, I know, of one chiropractic practice that is associated with an Orthopedist down in our area, and they also have the physical therapist associated with that group.
Could you just mention a few instances, where going to a Chiropractor has prevented individuals from having to have other types of treatment, where it may have resulted in a surgery or something like that?
MATTHEW PAGANO: I can speak to my own practice, and, I know, that I have helped people deal with acute lumbar disk, low-back, disc herniation and have resolved their situations, as opposed to them having to take the route of, obviously, much more invasive surgery performed, either by an Orthopedist or a Neuro Surgeon.
And that's an area, certainly, not exclusive to my practice. I would contend that we don't see, what might at first blush appear to be, a healthy population.
People present in my office with a variety of symptoms, many of which would not be deemed, quote, unquote, healthy. I think that argument is somewhat misplaced.
REP. GIEGLER: Thank you very much.
SEN. HANDLEY: Are there other questions? Senator Roraback.
SEN. RORABACK: Thank you, Doctor Pagano, for being up here, today. Some of what I've heard, and I've had a lot of interaction with you, my constituent, other Chiropractors in my district, some of what I hear is, hey, we do this already.
Don't pass a law, we always inform our patients of whatever the risks may be, am I hearing that, correctly, is it the custom of the business to do it already?
MATTHEW PAGANO: Very much so, as I can speak for the CCA, our association's protocol is to encourage our members to utilize informed consent. I can tell you about my, personal, practice.
I've employed a written informed consent form for about 8 years, now and in addition to that, I always have a discussion with the patient about the risks of neck manipulation.
I specifically use the verbiage stroke, I tell them that's an, infinitesimally, small risk. I explain that there are certain screening procedures where we take into account aspects in their history, and in their physical exam.
Aspects of that history or physical exam may indicate an increased risk, in which case, quite often, I opt not to deliver, what might be thought of as a traditional neck adjustment. I'll change my technique.
I'll use techniques that involve even less risk, to try to mitigate the risk to that patient.
SEN. RORABACK: So would it be fairly characterizing the position of the association to say, listen, we think informed consent is a good idea, just don't pass a law that applies uniquely to us, if you're going to pass a law, make it apply to every healthcare provider that provides any degree of risk in the procedure they provide?
MATTHEW PAGANO: Very much so.
SEN. RORABACK: Thank you, Doctor. Thank you, Madam Chair.
SEN. HANDLEY: Senator Fasano.
SEN. FASANO: Thank you for coming and testifying. Some of the testimony we've received, I don't know if this is yours, but we all received patient status at the time, informed consent, is that yours?
MATTHEW PAGANO: That is a form that we offer as the Association to our members.
SEN. FASANO: So this, in your association, Connecticut Chiropractic Association, this is the form that you guys give out to the people of your trade, and your association is suggesting that--
MATTHEW PAGANO: That' s an example.
SEN. FASANO: An example. Right. And I notice that you do have the issue that has been brought up by the two previous people, stroke is the issue for informed consent. And you do as a matter of course, and it sounds like the people of your association do it, as a matter of course.
But my understanding is there are two different chiropractic groups, organizations, is that an unfair statement?
MATTHEW PAGANO: No. In the state or nationally?
SEN. FASANO: Yes. In the state.
MATTHEW PAGANO: In the state, there are two groups.
SEN. FASANO: Do you know, whether or not, the second group is doing anything that is like this particular informed consent?
MATTHEW PAGANO: I do not know that.
SEN. FASANO: And if you do it, and you're having your association group do it, what would be the objection if its codified, since it's already being done, and, apparently, you believe that its good practice to it being done.
What would be the objection there to codify to make it a law, if, in fact, it's already being done in your association and, perhaps, not the other association, but, at least, in your association, and, at least, with you, why not make it a law then, what would change?
MATTHEW PAGANO: I think the inference of this bill is that in singling out the Chiropractic profession, the way it does, there is an abnormally increased risk associated with this one particular technique, when taken in context, in terms of all risk, across the spectrum of health care providers, it is relatively low risk, compared to the other.
SEN. FASANO: So, its not that you don't believe that this is an appropriate warning to give, because you do, it' s the fact that if it's in a law, it gives a negative inference and that's the issue?
MATTHEW PAGANO: Well, in practical application, the negative inference comes in the process of it becoming a law. I spent 45 minutes on the phone the other day, with a reporter from the AP, trying to sufficiently state the chiropractic position.
So we are being represented, already, in the public consciousness as having a risk associated with a treatment that all of us render dozens of times, every day, quite safely, and that risk is not there.
SEN. FASANO: Thank you for coming and testifying.
MATTHEW PAGANO: Yeah. My pleasure.
SEN. HANDLEY: Thank you very much. Our next speaker is Susan Todd-Scott, followed by attorney Robert Hirtle. Good evening.
SUSAN TODD-SCOTT: Good evening, Members of the Committee, my name is Susan Todd-Scott. I live in East Berlin , Connecticut . I have used chiropractic here since 1990 to get relief from painful injuries.
I have been the victim of three automobile accidents, and several falls that have left me in severe pain. During the last 17 years, dedicated and caring Doctors of Chiropractic have given me the very best of care.
Whenever I have seen my primary care physician, after an accident, the only treatment offered me was prescription painkillers. I refuse to take them because I have seen friends become addicted to prescription pain drugs.
Because of the care I have received, I look forward to a life without severe pain and the use of drugs. Because of the accidents and falls I have had, I, periodically, suffer from headaches, sciatica, and back pain. Some days it is difficult to get out of bed and go to work.
The headaches often affect my concentration, memory, and ability to work. Since I was the sole support of myself and my two sons, work was a necessity and not a choice. Before starting treatment with chiropractic, by Doctor Gina Carucci, we discuss my injuries and symptoms in detail.
After an examination of my injuries and an X-ray series, she suggested a course of course of therapy, providing spinal manipulations and soft treatment for my neck, hip, and spine.
Doctor Carucci has always been up front with me on everything and I have always consented to all treatments, as is evidenced in my signed informed consent form.
The outstanding care and the healing benefits that I have received from chiropractic care, for the most painful experiences of my life, greatly outweigh any risk discussed.
Over the years, chiropractic care has allowed me to reap the joys of raising my sons to spend quality time with my grandsons and friends and to be a productive employee. Chiropractic works, it has worked for me. I have a full life because of it.
I strongly feel individuals need to be their own health advocate and given the opportunity to choose what form of health care they wish to utilize. For these reasons, I take great exception to Senate Bill 1252.
This bill infers that Doctors of Chiropractic do not discuss their procedures prior to treating their patients. I don't believe that' s accurate. It certainly has not been my experience with Dr. Carucci, and the other dedicated Chiropractors I have been treated by. Every medical procedure carries a risk.
I realize that. But the risk of a stroke due to these types of manipulations is so slight that I am willing to take the chance. I would not enjoy anything approaching the quality of life without these treatments.
Senate Bill 1252 is not fair. It singles out Chiropractors in requiring written informed consent by law. Why just Doctors of Chiropractic [Gap in testimony. Changing from Tape 5B to Tape 6A.]
--and you should require every medical profession in the state to also provide informed consent. Singling out one profession is wrong. Thank you for listening to my story.
SEN. HANDLEY: Thank you very much for your appearance, your testimony. Are there questions? Thank you.
SUSAN TODD-SCOTT: Thank you.
SEN. HANDLEY: Attorney Robert Hirtle, followed by Mary, I'm not sure if it's, Levin or Levar.
ATTORNEY ROBERT HIRTLE: Senator Handley, Representative Sayers, Members of the Committee, I am attorney Robert Hirtle. I have been a practicing attorney for 45 years. I have represented the Connecticut Chiropractic Association since 1971.
I believe, I've had more exposure to the risks from the legal side of chiropractic than any other lawyer in the State of Connecticut . The Connecticut Chiropractic Association has as members, approximately, one-half of all licensed Chiropractors in Connecticut .
The other state association referred to, has about 50 members. So there is a distinct difference between the two groups. Let me say, first of all, Senator Fasano, has a misunderstanding of the reporting procedures.
There is a federal law which set up the National Healthcare Practitioners Databank. Every insurance company in the United States is required by federal law to report every claim made, if one dollar or more is paid on that claim.
So even in cases where a confidentiality order is signed, the insurance carrier, when they pay the claim, has to report that claim to the National Databank.
At the end of each month, the National Databank reports to our Commissioner of Health, the claims that were filed by insurance carriers against Connecticut licensees during the previous month.
Our state Health Department, by statute, is required to investigate, each and everyone, of those reported claims to determine whether or not licensure action should be taken against the doctor involved.
So Chiropractors are already covered by the National Practitioners Databank. Their Health Commissioner gets those claims and I can tell you, I've made a fair amount in legal fees, over the years, handling those investigations with the Health Department.
So I don't want to leave you with the impression that no one in the Health Department is doing their job, or they don't know about every single chiropractic claim that is filed and paid.
Secondly, I'm departing from my remarks, a little bit. They are important things, but these issues came up. Secondly, there is a misunderstanding of what informed consent is. Informed consent is a concept from the Common Law of Assault and Battery .
SEN. HANDLEY: Will you summarize, Mr. Hirtle?
ATTORNEY ROBERT HIRTLE: Yes. You can't touch another person's body without their consent. All doctors use informed consent. It's not something peculiar to chiropractic.
And the state association prepared a form with all of the stated risks, which you have in your materials, which you can take a look at, and that includes the risk of stroke, which I will tell you, in Connecticut , occurs once in 5 million adjustments.
We've had one stroke case, an average of once in every 5 years, in Connecticut . We have a million adjustments in Connecticut each year, by Chiropractors. Having said that, let me conclude by saying, that when issue came up, as to malpractice insurance, 20 years ago, this Committee and this Legislature solved it by requiring that all healthcare practitioners have medical malpractice insurance.
That included all healthcare practitioners. The same approach should be taken on something like this. Chiropractors don't object to informed consent, if they are responsible doctors.
If they don't use it and if they don't utilize the written form that is available for them, then they take the risk of being held liable in a judgment. However--
SEN. HANDLEY: Thank you.
ATTORNEY ROBERT HIRTLE: --the law should apply to all practitioners, alike. This Committee adopts a change in what is the current Common Law, by requiring that consent be in writing, it should apply to all healthcare practitioners, because you are changing what is current Connecticut law, the Common Law.
SEN. HANDLEY: Thank you very much. Are there questions? Senator Fasano.
SEN. FASANO: Attorney Hirtle, first of all, lets make it clear, I am not indicating that the Department of Public Health is doing their job, and those are your words, not mine, and that you said I said, I never said them.
ATTORNEY ROBERT HIRTLE: Well, you said, Sir, that claims were not reported to the Health Department because the claimant signed a confidentiality agreement. That's simply not true. That's not the law. The federal law is quite to the contrary.
SEN. FASANO: What I said was that the agreement allows them, because its federal law, to process it through National Practitioners Databank, which is what you're talking about.
And what I said was, that they are unable, themselves, the ones who were injured, by this agreement, to make any reporting directly to the Department of Public Health, as with most people who have been injured by a practitioner of medicine to make a reporting.
The point of my statement was that not only does your agreement say the person cannot make any type of reporting directly to the Department of Public Health.
But, in fact, even if the Department of Public Health were to find this information off the National Practitioners Databank, and were to call the person who was injured, according to this settlement agreement, that person could not, voluntarily, agree to cooperate with the Department of Public Health in pursuing actions.
In fact, the only way they could do it is by virtue of a subpoena. So the argument that I was suggesting was that perhaps there are not a lot of these logged in.
ATTORNEY ROBERT HIRTLE: Senator, you're wrong. Let me explain what happens. When the complaint is received at the Health Department--
SEN. FASANO: Madam Chair--
SEN. HANDLEY: Just a few minutes. Senator and Mr. Hirtle, Senator Fasano has not finished asking his question.
ATTORNEY ROBERT HIRTLE: I thought you were done, Senator.
SEN. FASANO: No. I'm still talking. So what I was suggesting was that by virtue of that, if the Department of Public Health were to call an injured person, that person could not talk to the Department of Health.
I'm just reading what the words say here, could not talk to the Department of Public Health. Maybe this particular settlement agreement that I have a copy of in front of me, is different from the vast majority that are out there.
But, certainly, talking to a few people, they have experienced the same thing. So saying perhaps that was the obstacle in order to receive the required information. I am now finished, Attorney Hirtle.
ATTORNEY ROBERT HIRTLE: Senator, that is simply not so. The Health Department appoints an attorney to investigate the complaint. The statement of an injured person, who has had a claim, is a privileged statement with the Health Department.
It is confidential. It is not public information, and it is taken on each and every one of these claims, unless the claimant does not want to cooperate with the investigation.
SEN. FASANO: Your agreement, it says the plaintiff and the counsel shall not voluntarily cooperate.
ATTORNEY ROBERT HIRTLE: First of all, that's not my agreement.
SEN. FASANO: I apologize.
ATTORNEY ROBERT HIRTLE: Secondly, I also represent people before the Health Department who have been injured, and who go there with this type of agreement, and who testify in confidence, before the investigators, and it happens everyday.
The Health Department, I can assure you, is doing their job, and they do it, diligently.
SEN. FASANO: I am not questioning the Health Department. Thank you, Madam Chair.
SEN. HANDLEY: Thank you. Representative Sayers and then Representative.
REP. SAYERS: Thank you. It is my experience from working at the Health Department and doing some complaint investigations that, frequently, attorneys will tell their clients to go and make a complaint to the Health Department to further reinforce any actions against the practitioner's license as part of that lawsuit. Would that be correct, Sir?
ATTORNEY ROBERT HIRTLE: Well, I would say the more frequent thing is to have the investigation after the claim has been resolved. However, some attorneys want to save money in preparing their case, and try to use the Health Department as an investigating tool.
But because of the confidentiality that I discussed with Senator Fasano, it's not a very effective way to practice law. I certainly don't do it and wouldn't recommend it.
SEN. HANDLEY: Representative Giegler.
REP. GIEGLER: Thank you very much. Just a question and you'll be able to tell that I'm not an attorney, by the nature of the question, but in your testimony, you said that Connecticut courts require more than mere consent, informed consent is required.
However, if our state doesn't require the informed consent, or if a patient who has been in to see a Chiropractor or in that case any medical profession how do they proceed with a claim of malpractice against the physician?
ATTORNEY ROBERT HIRTLE: The claimant would come into court and claim the doctor did not provide informed consent or that in his discussions with the plaintiff that an ordinary risk attended to that procedure was not discussed. That's why we have a written form, because we discuss all of the risks.
A jury then decides whether or not the risk was such that it should have been disclosed to the patient, and they decide if the risk had been disclosed to the patient, whether or not the patient would have accepted the treatment.
And understanding that part of the Common Law, dictates to a prudent lawyer, like, me, who represents Chiropractors, to have them use the form, so you don't get into court and you have the doctor saying one thing, and the patient saying something else.
My advise in risk management to the doctors is use the form, that's why we developed it and good practice is to use the form and the state association recommends that to their doctors. So that's not at issue here.
The issue of whether there should be a written form, informed consent, is something that's acknowledged by the professional society of Chiropractors in Connecticut .
REP. GIEGLER: And just to follow-up on that, it was stated earlier that half of the chiropractors in Connecticut belong to the Connecticut Chiropractors Association, and then, maybe, 50 to another association. But, however, this form is offered to the Connecticut--
ATTORNEY ROBERT HIRTLE: It's offered to every licensed Chiropractor in the State of Connecticut for use. And more than that, every insurance company also recommends either this form or a similar form.
So if a doctor is not using the form, like, these ladies said they didn't get informed consent, their violating the risk management procedures of the doctor's insurance company. Every insurance company recommends this.
REP. GIEGLER: Would it be fair to say that all those that belong to your Connecticut Chiropractic Association are utilizing this form that has been developed.
ATTORNEY ROBERT HIRTLE: Well, unfortunately, I'm not of the field, and I cannot say that. I know from past experience there is always 2% of society that march in a different direction than the rest of the troops, so you know, there may be some people, and, obviously, from the ladies that testified, they apparently went to doctors who don't follow the rules that the rest of the profession follow. And I'm sorry and it resulted in injury.
REP. GIEGLER: Thank you very much.
SEN. HANDLEY: Other questions. Thank you very much.
ATTORNEY ROBERT HIRTLE: Thank you.
SEN. HANDLEY: Our next speaker is Mary Lavin, and this is the last person to speak on Senate Bill 1252. We will then turn to House Bill 7159, and Steve Thornquist will be the next speaker. Good evening.
MARY LAVIN: Good evening, Senator Handley, Representative Sayers and Members of the Committee, my name is Mary Lavin. I am a Doctor of Chiropractic with 19 years of practice experience in the State of Connecticut .
I also serve as Legislative Committee Chairperson of the Connecticut Chiropractic Association and I am testifying on their behalf, today, in opposition of Raised Senate Bill 1252, AN ACT REQUIRING INFORMED CONSENT FOR CHIROPRACTIC TREATMENT.
If the bill that is before you, today, is because a constituent feels strongly about the concept and merit of informed consent, then each chapter of the General Statutes dealing with any healthcare profession should be amended to require both a written and verbal informed consent, with failure to comply being grounds for disciplinary action in all fields.
The Connecticut Chiropractic Association, as has already been said, already, recommends that their members utilize a written informed consent form and has made one available for use in offices.
It is not the concept of informed consent that we oppose, it is the, blatantly, unfair singling out of our profession.
If the proponents of this bill are here, because, they believe, it is the types of procedures or treatments performed by a Chiropractor that demand additional legislative control, then, this bill is still too narrow in scope.
The bill should include, at least, osteopaths, orthopedics, naturopaths, physical medicine and pain management specialists, occupational and physical therapists, athletic trainers, massage therapists, podiatrists, and dentists.
All of the above use, at least, some of the procedures that we perform every day, safely and effectively. If this bill is necessary for us, then it must be extended to include these professions.
Lastly, if the purpose, the primary underlying purpose of this bill is to require informed consent before manipulation of the cervical spine, because some constituents feel this procedure is too risky, then the scope of the bill continues to be too narrow.
Other professions, such as osteopaths, naturopaths, and physical therapists, to name a few, perform this procedure on their patients with far less training, I might add, than what is provided to the Chiropractors who perform the same skill.
The risk of stroke following manipulation of the cervical spine has been debated, but most agree it may occur somewhere between one in every 3 to 6 million adjustments. If this risk is too high, then everything with a higher risk ratio, should also have both written and oral informed consent.
SEN. HANDLEY: Will you summarize the conclusion?
MARY LAVIN: Yes. Thank you for giving me the opportunity to testify, today, I would be pleased to answer any questions you might have.
SEN. HANDLEY: Thank you very much. Are there questions? Representative.
REP. GIEGLER: Thank you very much. And thank you for waiting so long to testify. Just to go back to some of your testimony, you mention here a number of professions. And you mention that some of them use the same procedures as you, are some of these, or do they, actually, use manipulation?
MARY LAVIN: Not all of them use manipulation, but the thing that confuses me, about this bill, and, I think, also confuses the general public, is the way it's phrased. It says nothing about manipulation of the cervical spine.
It says AN ACT REQUIRING INFORMED CONSENT FOR CHIROPRACTIC TREATMENT, for all procedures and all treatment in a chiropractic office. The way that bill is worded, it' s on every procedure that we do in our office and the first group that I listed, do a number of the procedures that we do.
We all have pain management, we all use physical therapy modalities, so if you're going to make it as broad as that, then those groups have to be included under this bill.
REP. GIEGLER: Then we get into the education point, and I am sure that you have to do continuing education within your profession?
MARY LAVIN: it's required by the state. I believe its 48 hours every two years.
REP. GIEGLER: Every two years?
MARY LAVIN: Yes.
REP. GIEGLER: And then would that include manipulation and the cervical and the neck?
MARY LAVIN: There's not specific requirements on what you have to do your education in, however, for instance, my malpractice carrier, they offer courses, and if I take a risk management course, I get a 5% reduction in my malpractice rates.
So, of course, most people take advantage of that and do the advanced training and find out what the risks are and how to test for them, and how to incorporate that into your examinations.
REP. GIEGLER: Thank you very much.
SEN. HANDLEY: Thank you very much.
MARY LAVIN: Thank you.