Lawyers PI Program



Quickie Consult #88

 From the Desk of:

 Mark Studin DC, FASBE (C), DAAPM, DAAMLP 

Critical Triage



This consulting session is my personal standard of care after treating the injured for 28 years. It is not intended to direct the care of your patients in any way and is not reflective of any one patient’s condition. You must decide based upon your own clinical results, what is needed for your patient. This is solely for informational purposes and is not to render a medical opinion and/or advice.


This is the most important consultation I have ever written and as a result, I am writing it both as a “Quickie Consult” and a full “Consultation” to ensure that you read it.


I have made it a practice not to comment on how you care for your patients. Over the years, I have often been asked, “What is the best technique to care for injured patients?” My answer has been steadfast; the best technique is the one that works the best for you. That still holds true today, as chiropractic is often magical; patients get well no matter what technique is used and after 28 years of talking to doctors across the nation, I firmly hold that not as a belief, but as an observation of 1000’s of doctors’ and patients’ testimonials.


I know there are those that are adamant that certain techniques accomplish results and others don’t, and I am sure there is evidence-based validity to those arguments. However, it is not my goal or intent to get into the technique realm, as I am not qualified to weigh in on what is best and not. What I am imminently qualified to discuss is triaging the injured and that is the focus of this discussion.


In my formative years of practice, I made too many mistakes based on simply not knowing. I was never exposed to proper diagnosing, partly because the technology wasn’t yet invented and partly because I was dogmatically convinced I could “grow hair on a cue ball” and “cure lymphogranuloma inguinale” with an adjustment.  I also had no experience in diagnosing, beyond a clinical evaluation, to determine subluxation. Yes, in professional school I studied differential diagnosis, as we all did. However, I really didn’t take it to heart, as I only wanted to unsubluxate patients at the expense of those who needed other care as well. You cannot make the same mistakes that I did because now you know. You know why, when and how to triage the trauma patient because I have taught you all throughout the consultations.


Over the last few weeks, it has become increasingly evident that I need to spell this out in clearer language, as many of you haven’t gotten the message and are headed down a dark road. I know, I have been there at the expense of my patients. My protocols over the last 2 decades have been simple; during a standard history and examination, if a patient has signs and symptoms of radiculopathy or myelopathy that is correlated with a clinical evaluation, I order an MRI of that area. That follows complete x-rays to rule out osseous pathology, and all of this occurs prior to treatment.


Insurance companies try to dictate patient care by denying payment to an MRI company if the test is ordered prior to 4-6 weeks of conservative care. The reason they do that is because they can, not because that is what is best for the patient. It’s always about the money! The MRI company in turn will pressure you to follow that protocol because they want to get paid. The truth is, the MRI company will get paid if your testing order is thorough and they will subsequently accept all of your referrals because they can get paid with you instead of getting denied BECAUSE of you.


Remember the previous consultation of “Prescription vs. Script?” There is a reason why some offices have better PI practices and it has nothing to do with PI practices; it has to do with clinical excellence and a higher level of patient care. Lawyers will want to work with doctors who are more aggressive in ordering MRI’s. I am not saying that others don’t want to order MRI’s, but if the MRI company will not take your referral because your documentation is so poor, you will have no MRI results to show the lawyer. Therefore, the lawyer will not want to work with you.


That still isn’t the problem and I only said that to get your attention. The problem is that you are caring for patients that have a potential compression of the root or cord and you don’t know the etiology, yet you blindly “dive in.” Here is the language most of you use in triaging patients:


“Mrs. Jones, I suspect you might have a herniated disc or some other problem in the area of concern. I want to start you on a 4-6 week regimen of conservative care, consisting of therapy and chiropractic adjustments, and I will be gentle. After that period of time, if you still exhibit the problems, I will order an MRI to see what is going on. Does that sound reasonable?”


The patient will usually acquiesce to your ordersk, as you are the doctor and they do not fully understand, as it is all Latin (literally). Here is what you are really saying:


“Mrs. Jones, there is something going on in your spine, but I don’t know what it is. However, I am going to guess that you will be okay if I deliver high velocity thrusts into your spine and/or start exercise rehabilitation, creating increased weight loads and increasing the lesion in your body (by increasing intra-thecal pressure), hoping to help you. In my heart I really think this is my best guess, but if I am wrong, you could end up needing avoidable surgery, a paraplegic or worse, if I am way off. But I am confident I guessed right, so lay down so we can get started?”


The difference between the first and second statement is the first is eloquent BS and the second statement is factual. The truth is, if you told the patient the truth, it would be the last words between you and your patient…ever.


Where do you stand?

You now know better.


Your role as a doctor is to create an accurate diagnosis and prognosis prior to creating and delivering a treatment plan. Diagnosing means knowing what is wrong with your patient prior to delivering any type of care. I was the most anxious doctor in the world…I wanted that patient under my hands so quickly so I could get them adjusted, and I was simply wrong in those formative years.


The protocol is simple; if there are any clinical signs or symptoms of radiculopathy or myelopathy, x-ray and MRI prior to adjusting. If there is any space occupying lesion touching, compressing, abutting, effacing the cord or root, send your patient to a neurosurgeon for a second opinion to ensure you didn’t miss anything. This is a non-negotiable protocol for me. Learn to read the MRI’s, as you will then maintain control of the care of your patients and there will be no guessing.


This is the core of the reason for the MRI Spine Interpretation Course. Not so that lawyers can see your credentials, although that is a secondary and valid reason. For too many years I was in the dark and had to rely on others for me to know if it was safe to adjust my patients.


I felt it was simply wrong for me to abdicate the responsibility of the decision of whether to adjust my patient or not to a medical radiologist or neurosurgeon no matter how much they understand or like chiropractic. That is my clinical decision, my patient and my license on the line, which I worked too hard to place in harm’s way. The other problem is once I started to read my own films, I realized that the general radiologist was often wrong in his reading of the MRI’s and I was making decisions based on wrong information and therefore rendering the wrong care.


In 1989, this failed patient triaging protocol cost me a malpractice suit and licensure issues that dragged on for 11 years, not to mention too many years of sleepless nights. I have resolved to never let that happen to you. I mean that seriously; it is a situation you are in control of avoiding and for your patients, yourself, your practice and your family…gain control over this aspect of your life. Unlike so many practice issues you can’t control, this one you can.


I wish someone had told me this before my nightmare began, one that was created solely because I abdicated the responsibility of diagnosing to a medical specialist who was wrong. As a note, nothing happened to the medical specialist who misdiagnosed the patient and that should come as no surprise because chiropractors are judged at a different level than medical doctors, usually because we are judged by the medical profession, in part, as part of the process. I didn’t say it was fair; it just is until we change it…A topic for another conversation.


Take the MRI Certification Course. I didn’t start writing this consultation to come to this conclusion. However, as I continued writing, I realized it is the only solution to the problem and currently the only program of its kind in the world. It will teach you how to read your own MRI’s. It will teach you how to make the clinical judgment of when and when not to adjust your patient. In the 6th module there is a discussion between myself and a world class neurosurgeon that is historic and will give you the clinical guidelines on what the indicators are in deciding when it is reasonable to adjust your patient and when to wait. You will be in control of your patients and career with this knowledge. This knowledge will empower you to be the best-of-the-best through clinical excellence and underscores the reason why some have thriving practices and others fight to survive. Take action, take control and win in your practice life and your family life.