Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 1114
Lawyers and Medical 68 L

From the Desk of Dr. Mark Studin
Academy of Chiropractic

Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006

"The tools required for MD PCP's to refer"


Dr Studin: We really were working very hard on academics and we're working hard and infiltrating hospitals and we're working hard with lawyers and, and primary cares and it's working. It's working really at an unprecedented rate. I mean, there are some doctors who are struggling, but for every one that's struggling, I think there were 10 that are thriving, in the programs that we're doing and the thing that we've come up with, and really you came up with this and it's something we've been talking about but we haven't been put into words, is we've covered the academic infrastructure that doctor needs to be a primary spike yet provider, and we're constantly adding new programs and doing what we need to do. We've created a fellowship and we're actually working with multiple organizations and attorneys to increase the stature or recognition of that fellowship. we're getting into primary care offices, we're getting into surgical offices, now we're up to the next pressure point and it's a worldwide phenomenon that we're going to resolve and that worldwide phenomena that you have tangentially identified in your clinic by being an adjunct professor at the state University of New York, Buffalo Jacobs School of medicine and biomedical sciences, that you've identified and you with your residents that rotate through your offices. They don't know how to refer to Chiropractic or when or to whom. Would you say that's the next roadblock or the ultimate roadblock?

Guest Doctor: Yeah, because remember historically it was these guys are charlatans. They have no education. Then the second evolution came, they're good for a certain thing and if my patient needs spinal manipulation, I will refer that to a chiropractor. We were seen as a modality.

Dr Studin: We were seen as worst to a PT.

Guest Doctor: Well, that was their criteria of identified chiropractic as a modality.

Dr Studin: I'd like to have a just comment on what you just said a moment ago before you move on. It talked about, first it was, we're not going to refer to them because they're quacks and charlatans. I've been around a lot longer than most when I get out of school in 1981, when I was in practice for years, I was invited to lecture to every single medical student at the State University of New York at Stony Brook School of Medicine. There were maybe 300 or 400 medical students in the room and they invited me to be on a panel with Orthopedic Surgeons, physiatrists and neurologists and me. I did realize that I was set up and a pediatric orthopedic surgeon, which is the head of the department, and I still remember his name, Martin Gruber brought me up there and said, this is Mark student of chiropract, I want to let everyone know that yes, he's a chiropractor, but from my perspective he's a quack and a charlatan, but I brought him to here to defend themselves. I mean, and here I am in practice three years. I have no knowledge, no ability, but also in the 80s, there was no research behind this. It was all philosophy. Thankfully a medical student stood up and said, doctor, that's not fair. Because even the use of aspirin on the book they studied from, there's no reason we don't know why aspirin works, but we still prescribed that. And if it wasn't for Chiropractic, I'd be a cripple. I have very little to say after that, all I said was I liked what he said, so why don't we just move on. So also in the 60s, there was a book app called AMA in the public interest, there was a guy named Doyle Alexander who was on the committee on the AMA. They had an actual committee. But the real purpose behind this was to rid the world of chiropractic. So, they wrote false research articles and disseminated them into every medical school library and every public library in the country through the medical to the state medical societies and the counties. And they disseminated them. They even took dear Abby, the syndicated columns and put false information in her columns nationally and it was very systematized. And then he wrote a book called in the public interest AMA, the guy named William Trevor wrote the book and exposed all just like the ice spy movies. He went in the middle of the night with his little camera because there was no computers he took microfiche pictures and took pictures of all these internal documents. And he wrote the book, after it was published, like three days later, the rights were bought out by a parent company, in conjunction with AMA, and then that Guy William Trevor disappeared off the face of the earth. I happened to have gotten a copy of the book, and it's impossible to get right now. But when you talked about quacks and charlatans, we as chiropractors have to understand that our history is tough to get here. When you look at Chester Wilk sued the AMA, that was huge. That was our first foray in to say you can't keep discriminating against us. Some of that discrimination still exists within the older guard in my mid-sixties right now, my generation still remembers that, what built your generation just hears about it. So, most of the younger medical providers are really excited to work with us. We're the older ones still have to work through that prejudice. So, I told you all of that because that sets the stage for really where a lot of organized medicine control were their mindset was created about car pricing years ago.

Guest Doctor: I agree with that. And it wasn't until 1986 as a matter of fact that the AMA officially, removed its statement or its position that it was unethical for MDs do associated with chiropractors, 1986. So when we talk about building relationships, my perspective particularly with clients is, any MD that went through their training in 1986 is really somebody that you're not going to have a lot of in roads, because they were trained on that bias.

Dr Studin: it's going to be hard, not impossible.

Guest Doctor: But they're easier docs than work with now, but in the grand scheme of training, there's a lot more MDs out. So at first it was crack, Charlatan, Second was chiropractic’s are modality. If my patient needs that modality, I'll consider referring, but they always thought that we needed oversight. And that's why PT would always win out because they're like if I'm going to have to oversee it, provider, I'm going to do what's familiar.

Dr Studin: Or what they can own, because it's always about the money. How many PTs sites or MD are owned.

Guest Doctor: I think that trend is going away. I agree. Every orthopedic group had a PT, every pain management group at PT, and because Madison is becoming specialized and procedural, they make their money doing injections and surgery, not managing you're managing cases. But now we're having inroads, we have doctors in multiple states, that are in front of very large medical groups. We have members in our, of the Academy of Chiropractic that are part of medical homes, accountable care organizations, and they're working at a high level. So the event accepted and now we get to the big issue, which is, hey mark, I'm a primary care doctor and I look at Dr Studin and I say, hey Dr Studin. Wow, they do really great work. I love what you do, I can see your CV, I could see your training. How do I know when to send a patient to you? Because I think I have to send them to orthopedic or neurosurgery consult or for Rehab. I know you work and I know patients love you because they come in and tell me that, but how do I refer to you now quickly, you and I have always had this discussion that we're kind of against put out what would be called, but we don't want to establish care paths or algorithms because historically from power proctors do that.

Dr Studin: Let’s use the word guidelines.

Guest Doctor: Guidelines are always used against our profession. So how do we create a way for a primary care doctor to understand how to use us without it being restricted for our profession?

Dr Studin: There's two separate issues, and I see people quoting the most quoted guideline is the cross guidelines because since the most kind of a friendly, now I love Arthur Cross. He is the smartest man in the world. I don't believe he goes around the country and lectures anymore, but the cross guidelines, who's off the cross? he's not an academic institution. He's not a licensure board. Yes, there are many organizations that have approved this guideline, but their political, it's like the ACA/ICA, their political organizations designed to further our profession. I'm going to give you right now from an in the office guidelines, the best one that has ever been created that will endure the balance of your career and can never be refuted. Which is not the same as the conversation we're discussing now is how to give a guideline or a care path or a flow chart to a medical primary care provider to refer to you, Totally different. But here's your in-office guideline. It's your last evaluation or Revaluation that's your guideline. And there's nothing in the world better than that based upon your clinical evaluation history and clinical evaluation, Ortho, neuro reflexes, complaints. Are they getting better? Are They not getting better? Have they MMR right? Are they have a progressing? You are last evaluation is the best guideline in the world and it can't be refused because it's what's happening today about your patient. And it has nothing to do with population based studies. Now talk for a minute about us, West Stream, neck and back index.

Guest Doctor: it's nonsense, right? So when you look at assessment tools, there's two things that are really critically important to understand. Outcome assessments were designed to homogenize patience for the purposes of research. So how do we take somebody with a regional spine pain and how do we measure them as a group and how do we put them through the stages of doing research? That's what they were designed for. They were never designed for clinical practice. So when we talk about patient centered care, which means the individual patient is going to be cared for, those population based assessment tools are ineffective because that's not what they were designed for. They were adapted by workers' compensation, carriers and occupational health people.

Dr Studin: Yeah, but who does it help?

Guest Doctor: It helps the counters in the managed care organizations and the insurance carriers it helps.

Dr Studin: Because it limits your care because they're looking at a whole population, not your patients. What does your patient have to do with a whole population they study a million people? Half a million people be far left. Half a million people far right. What about your patient right in the middle where their statistic lies your patient? It might not be there

Guest Doctor: No. And I agree and that's the first problem. The second and the more contemporary problem with this is were moving beyond regional spine assassinate or the idea that the lumbar spine acts independently of the thoracic and the cervical and the pelvis. When we adopt in the literature starting to adopt this whole spine model, and whole Organ system, just like every other systemic system in the body, spine is one unit. How can you take a regional assessment tool when we're moving into a whole spine model? You can't, it's so outdated, it distracts from really the future. So as chiropractors and leaders in spine care, that's something that we have to move to exactly what you just said Mark, is using our patient's response to our character dictate the care path.

Dr Studin: Now with respect to that we talked about the historical problem. We talked about the guidelines issue, but if the medical doctor does not have a guideline, how do they refer to us? What do they use? if hurts there is a drug. Go see an orthopedic surgeon. That's what they did. Or even say, go see a PT. They said, go see an orthopedic surgeon for spine. Or if it's really bad in as radiating goes, go right to the neurosurgeon. They do not segment usually into pain management. It's Ortho surgeon, a neurosurgeon to manage the case. How do you change the culture of an industry of medical primary care providers that govern 95% of our population? How do we change that industry? How do we educate them? What do we do? Obviously, we can't give all the answers right now because they're not fully developed. But we're going to explain what we're going to do and why we need to do it. And in our primary spike here, symposium, and October 2019 18th, 19th and 20th in New York, we're going to be outlining it in detail. If you are listening to this before then be in New York, October, 2020. If you're listening to this afterwards, we'll have already developed that for you and then have an outlines in detail to be able to share with you. So Phil, from a brief synopsis, what are we going to do?

Guest Doctor: We're going to offer a tool to the medical primary care doctor that would essentially be able to quickly and effectively screen the patient in order to get the properly trained chiropractor to do a full clinical assessment on spine pain patients. I think that's probably the easiest way to explain it.

Dr Studin: Let's give an analogy. Spike care in our society is upside down. If you have a really bad headache, you're short of breath and you sweat, what do you do? You go to your primary care medical doctor, you go and you give them a history. They do an EKG. They'll listen to your heart. They'll check your pulse, they'll listen to your lungs, and then they'll give you some medication, something to lower your blood pressure if your blood pressure's elevated, by the way, your pulse is elevated. They'll give you some medication to be able to manage it. They're not fixing anything. They just want to manage it. They'll talk to you about diet or talk to you about stress, and then they'll send you home for two or three weeks with the medicine. You come back in two or three weeks. It's either resolved, they might take you off. They might keep you on for the rest of your life. You don't know. Usually it's keep you on for the rest of your life, but if it's not resolved, they're going to send you to a cardiologist. Cardiologist is going to do a stress test. They're going to do another EKG. They are to do a doppler via carotids. They might do a thallium stress test. Whatever they're going to do more testing to see what's going on at a higher level. You come back and then they're not fixing anything, they'll tweak your medications after that. You come back. If it's still bad, they send you to the cardiothoracic surgeon for consideration of a bypass, whatever surgical stents, whatever will cardiologist does, we'll bump it up to an interventional cardiologist for a stent or a bypass for a cardiothoracic surgeon and that's an appropriate, reasonable way of managing cardiac issues in medicine, again, no one's fixing anything. But they're managing the pathology that's there. What are we doing in spine care in our society? You go to your primary care, you say my back hurts, they send your rights to the surgeon right to the top. Can you imagine if your primary care medical doctor, every time you had a little bit of a shortness of breath and sweating, you went right to the cardiothoracic surgeon, think of how absurd that is, just from an emotional or medical perspective, think about how absurd that is. They have many more unnecessary surgeries or if you're encumbering unnecessarily the time of that surgeon whose time is very short. But that's what we do in spine care, right to the surgeon. Now the other thing is general orthopedic surgeons should never ever touch a spine, only neurosurgeons or orthopedic surgeons that have done a fellowship in spine, and I'm really emphatic about that. But what we're going to do is create a flow chart, so to speak. We're going to start to create an entire educational program to educate the medical primary care provider on when, how, who to refer into Chiropractic, when to refer, how do you refer, and who do you refer to? Very simple. So we're going to create a series of parameters so that they will have tools within their hand to know when to refer to a chiropractor and not physical therapists and not orthopedists. We're going to do it based upon the evidence in the literature because some fraught right now with a tremendous amount of stuff. Then we're going to teach them how to do it and it really, it's just a prescription pad or a phone call. Then the last question is who? we're going to really ramp up our trauma qualified doctors, our primary spine care qualified doctors, and we're going to really put that forth out in our society at a much higher level. We're going to work on getting published and I'm going to put this out there, so we're forced to do it. We're going to work on getting published in the primary care journals with medical primary care providers and with Dr. Rollins relationships and medical school, some of those departments, if they've got a lot of clout with publishers to get things published and talk about collaborative care and talk about chiropractic managing these cases. These are all the things that are currently underway, and it will be shortly done, but we need tools that our society needs tools, the medical community needs tools right now were pretty much accepted, but they just don't know how, where or when. And these are the things that are being developed as we speak by both. So there's anything else that I missed?

Guest Doctor: No, I think that that's an exciting time. And just to finish up your, when I had the conversation that I had with one of our clients this morning, he said it's a real funny, when you look at medicine and when they look at a spine pain patient, they may diagnose low back pain and he said it perfectly. You said the ICD 10 code a M54.5 which is low back pain, so that’s the symptom. So medical doctors historically have been triaging based on a symptom, not on finding the cause. And that's our job and that's what we're going to teach.

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