Academy of Chiropractic
MD Referral Program
Administrative Pillar – Program Overview – Apprentice
William J Owens Jr DC DAAMLP CPC
“If you do NOT have a plan, you are part of someone else’s” – Terrance McKenna
EGO vs. CHIROPRACTIC
When you are trying to build relationships in the community, sometimes there are situations where you have to make a choice about how to react. I had such an experience today. A patient of mine was injured as a result of an automobile accident and was being treated at my office for approximately 3 weeks. I had made contact with her primary care physician’s office, sending the initial report, MRI studies, etc. Here is what happened:
The patient came in for a follow up visit about 2 days after I sent my notes over to the MD’s office. The patient told me that she was contacted by the “front desk person” from her doctor’s office who said, “Do you know that you have a herniated disc?! You need to make an appointment with a neurosurgeon!” The patient came into the office VERY upset (crying, in fact) that she was going to need surgery. Now, the MRI findings in the cervical spine were not at a level that a surgeon needed to be involved 3 weeks into care. There was a central disc herniation at C4-5 and a right paracentral disc herniation at C5-6. There was no cord compression or instability present on the flexion-extension radiographic or MRI views. I sat the patient down and explained that I work with surgeons on a daily basis and the current findings on MRI would not interest a neurosurgeon in the least, and frankly he/she would consider it a waste of office time. I went on to explain that chiropractic care directed at increasing joint range of motion and decreasing pain and inflammation (reducing subluxation) was what was appropriate at that time. She needed continued care, but based on my findings, we needed to treat her based on her response to care.
THINGS WERE GOOD FOR ANOTHER WEEK AND THEN…
I came into the office today and saw that the patient had canceled her appointment and did not reschedule. My front office said that [PATIENT NAME] called to say that she saw her primary care doctor and he told her to discontinue chiropractic care and to go to physical therapy…DID THAT EVER HAPPEN TO YOU? This is NOT the first time it has happened to me, nor is it likely to be the last…
I HAD TWO PATHS TO TAKE…YOU KNOW WHAT THE FIRST ONE IS AND IT IS THE FIRST REACTION TO SUCH A SITUATION. THE SECOND IS THE MORE LEARNED APPROACH…
Based on past experiences in building hospital clinics and working in a multidisciplinary setting, confronting the MD and “discussing” this situation may not always be the best INITIAL solution. My practice is busy and one patient is not going to keep me from feeding my kids…I have decided in the past, and did so again today, to let things play out a bit. (Keep in mind that this decision was based on past successes…successes to the point that many of my best relationships in the medical community started in the EXACT same way this one did!)
The IMPORTANT thing is to realize is that your relationship is between YOU and your PATEINT, not YOU and the MD…Therefore, I called the patient and made this a teaching moment. My goal, over time, is to make BOTH parties realize that I am RIGHT when it comes to treating and coordinating care for the traumatically injured.
Here is the conversation I had when I spoke with the patient. This is a time to TEACH the patient that what you had done or suggested in the past was appropriate. This builds trust:
ME: “Good morning, [PATIENT NAME]. It’s Dr. Owens. The staff told me that you canceled your appointment today. I am calling to make sure that everything is okay.”
PATIENT: “Yes, I saw my family doctor yesterday and he told me to go to PT.”
ME: “I see. At your office visit with your family doctor, what did he say WHEN HE REVIEWED YOUR MRI FILMS WITH YOU?” (I was under an assumption that he probably didn’t, but even if he did, he is not trained to read them himself.)
PATIENT: “He said that I have some ‘bulging discs’ (incorrect assessment) and that I need to see the physical therapist for a while to see if that will help. He also said that he ‘had no idea’ why the nurse practitioner would have referred me to a neurosurgeon; my findings are not significant enough…It was just like YOU said.” (Okay, POINT FOR ME…)
ME: “[PATIENT NAME], when you have chronic pain, pain that has been around for a long time, exercising and strengthening those areas can be helpful. That is different from being injured. Rehabilitation is MOST effective when the swelling is reduced and you have full range of motion in the spine (subluxation reduced). Otherwise, it’s like slapping a sunburn. My concern is that you are going into the rehabilitation phase to early…Correction, rehabilitation à stabilization. Please make sure that you watch out for your pain getting worse with the rehabilitation. That is an indicator that you are doing it too early and it MAY INTERFERE WITH YOUR GETTING BETTER.”
PATIENT: “My doctor said that it is going to hurt, but I have to WORK THROUGH it.”
ME: “[PATIENT NAME], remember that is okay when it comes to chronic pain, but you were INJURED and TRAUMATIC INJURIES need to be treated differently. (I am setting the stage to be proven right, AGAIN.)
PATIENT: “Okay, that makes sense. I will be careful…My doctor says that after the PT, he wants me to go back to you for continued chiropractic care to make sure that I continue to get better.” (NOT what I was expecting to hear! If I went with my first reaction, to call and confront him on his poor decision making, I would have looked like a selfish loser and potentially ruined the opportunity to TEACH this MD about chiropractic in the long run.)
ME: “[PATIENT NAME], my job is to make sure that you are cared for and get better in the shortest time possible. Regardless of whether I am actively treating you, I am here to COORDINATE your care and make sure that you are being treated properly. If you feel that the rehabilitation is too aggressive or you feel worse, please make sure that you call me. I am here to help you.”
PATIENT: “Oh my god, thank you so much…I was afraid that you would stop helping me because I was going to PT for a while…I will defintitely call you if I feel worse and will see you after PT.”
I have dictated a note in her chart that I spoke with her and summarized what I said above. This letter will be sent to the PCP, relating that I will continue to monitor her care and will re-evaluate her condition when she returns to chiropractic. (This shows that I am a team player, a patient advocate and not a jerk. Remember how the MDs in Florida directed care…Those doctors that were uncooperative and overall not PLAYING NICE. Patients were directed AWAY from them…)
This will set the stage for a probable professional, “I TOLD YOU SO” later on. The language should this occur will be:
“[PATIENT NAME] underwent a trial of rehabilitative care which increased her symptoms. We will be working to reduce inflammation, increase joint range of motion and control pain. Once this is established, we will WORK WITH YOUR OFFICE TO GET her additional strengthening and spinal rehabilitation for long term stabilization. Although this has set her back a little, I am confident that she will make good progress long term.”
Based on my experience, what is likely to happen is that she will go to PT for 3-4 visits and get worse. She will call me up and say that PT hurt. I will remind her about the difference between being injured and having chronic pain and will get her into the office the following day. My re-evaluation to the PCP will include the above stated language AND A SPECIFIC TREATMENT PLAN.
If the less common thing happens and she gets better, I will get the patient back anyway. Either way, THE PATIENT WINS and I avoid hampering a possible long term relationship in the community.
Please understand that I am not lying down, taking orders, or diminishing the role of chiropractic in the community. I will be looking for opportunities to TEACH the medical community about chiropractic and to do that we sometimes have to check the EGO for the greater good. Should this become a habit in the future, he will be getting a phone call to remind him what happened last time rehabilitative care was prescribed too early…