Academy of Chiropractic

Quickie Consult 1200
Office Systems 113 OS

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

"Getting Outside Records and Delayed Ordering of MRI's"

 

Dr Studin: Start from the beginning again please.

Guest Dr: an attorney I'd worked with previously, I'm on a couple of cases and he wanted me to work up this couple, they had been in a crash, it was about approximately a year previously. So the man had shoulder surgery, the wife had a like workup, so that's significant Care in the past, they were being referred to physical therapists two hours away. So it's too far of a drive.

Dr Studin: you live in a remote region. So that's important to know, go ahead.

Guest Dr: So I am about an hour from them, so it was better, it was closer. So I said, maybe you can get in and I do a better job with spine pain. So I got them in and did fairly well. Got them even an hour drive. One way to do that, over a couple of months they got in probably 25 visits or so approximately. But the problem was getting the medical records from the previous medical doctor. And so we are sending requisition try to get the report, the problem was that he told me in his intake that he'd had an MRI and so I assumed it was spine because he had of course all this, it was a very severe crash, high speed, totaled car, so now I'm finished their case trying to do their final and so I get them in for the final exam and that's still at that point I haven't got records. So at this point in our state we have like 30 days As chiropractors. Otherwise it's like a board violation to not get records. I assume it's probably similar with the medical doctors. So we get about the point, we're going threaten them. So the problem was I finally get the records and he had shoulder MRIs, never had spine MRIs. So like I can't like finish. So my question for you is, we've talked about diagnosis, prognosis, treatment plan. If I get an MRI a year and a half after the fact, I know will give you age dating and I have a problem with that. So my question is, is there unethical for me to order MRIs purely for getting being able to finish the case?

Dr Studin: Yes, it's unethical, there's two issues that come into play here. Number one with records in every state in the country It is a license violation to withhold records for a coach reading doctor, and this is a primary example, you sends a request, you don't get a response. You give 48 hours. Then you call the doctor's office and say, I sent a request. I'm treating this patient. I need to see the records. I sent the request two days ago. I need them within 24 hours, if you do not have the records sent to you, you call up a third time. I'm letting you know I'm faxing over another request. And in that request, I am letting you know that we're putting you on notice that if we do not have the records in 24 hours, I am reporting you to the state licensure board for a licensure violation. This patient had a serious accident where care was in limbo. I don't know what to do and I can't move forward. And you're delaying necessary care that will be a licensure complaint against your license. Just pair you in, then you have 24 hours, this is my third request and you send it. And then if they don't send it within 24 hours, send the complaint to the state medical board or chiropractic board and CC a copy to them and their fact they know that you weren't kidding. Number two, the only reason you order an image is to satisfy a diagnostic dilemma. do you think that there is a potential spinal cord, root nerve, anatomical issue that needs to be fixed?

Guest Dr: Anatomical nerve root?

Dr Studin: like a herniated disc, a fracture. right now today, does the patient have an unresolved diagnostic dilemma of a radiculopathy or myelopathic components in our world?

Guest Dr: No.

Dr Studin: has pain persistent for greater than six weeks and you don't know why?

Guest Dr: Yes.

Dr Studin: Then there's your question out, this persisted for over a year, and I cannot determine why. Now, if you're opening up a Pandora's box though, because the other issue is, is you close your eyes and go, I know if you get the well, I know I can get them. Well, because you had this same clinical scenario for a year and a half and you did nothing. You're more guilty Then the doctor was holding the records because you actually laid hands on this patient 25 times or maybe the last 15 times thinking that I don't know what's wrong with this patient. How come they're still in pain?

Guest Dr: I would assume it was just biomechanical. So I'm curious.

Dr Studin: The patient has pain. So you're on the witness stand defending your license right now, doctor, the patient has pain for a year and a half. They got better to some degree. But that pain persisted, you assumed that was biomechanical but does not find mechanical issues resolved in a period of time within 18 months, yes or no is a rule.

Guest Dr: Well yeah, but it was about a year.

Dr Studin: So 12 months as a rule, does it usually a baked by then? Yes or no?

Guest Dr: without care?

Dr Studin: with care.

Guest Dr: They didn't had care. That's when it came to me.

Dr Studin: During your 25 visits, how long was that For?

Guest Dr: Two months.

Dr Studin: In that two month time, did the pain of bait go away?

Guest Dr: 100% No.

Dr Studin: Did it go away to the point where you were comfortable after there was nothing else going on? you can't even answer that question appropriately, and this is just you and me. Your clinical will take you just so far, in our world It often is symptomatic, but sometimes it's not that. Then we've got five mechanical failures to look at. But if a patient has pain that persists after six, seven, eight, nine, 10 visits, look, you've how many years you were in the game?

Guest Dr: 31

Dr Studin: I'm in 39 you and I both know the problem with chiropractic is patients get better too quick. They get out of pain too quick and you often don't have a chance to fix their underlying problem. But when they don't get out of pain and you're damn good at what you do, you don't even have to think about treating someone. Do I have that question? You have to want aggressively go after those records and if you can't get the records, order another MRI even without the records in your hands because something's persistent That might've been different from the MRI that they claimed they had six, eight, 12 months. It's unethical to order an MRI just to make a case. Is it very ethical to order an MRI if the pain is persistent and you don't know why.

Guest Dr: Got it now, now the real world. what do I tell? go to the attorney and tell them, I screwed up? What do I, how do I?

Dr Studin: you go to the lawyer and say, I screwed up. Tell the truth. So it shall set you free. The doctor stonewalled; he didn't send me the records. I should've reported them to the licensure board, But when the patients said that he had MRIs, MRIs was of a shoulder, not spine, and I should've aggressively gotten the records or another MRI. But at this stage of the game, the patient has persistent pain and I don't know why. And I want to order an MRI. I want to order it now I want to see what's going on. I feel like something was missed, and you tell them, it's on me. It's not on the other doctor. This is on me because I should have known better. And I tell people the truth, no one's perfect. People appreciate honesty. And if he doesn't want to work with you from here forward because you messed up, it's better than lying And then he finds out later on. That all of a sudden your reputation is destroyed. But you and I are constantly professionals. Some lawyers and coach treating physicians are petty and they won't have the level of maturity We will, and just chalk it up to a learning experience.

Guest Dr: Should I call to tell him I think we should get an MRI this late in the hunt.?

Dr Studin: it is not this late in the game, the patient today has persistent pain. Why? you don't know.

Guest Dr: so you're saying that is okay.

Dr Studin: Yeah, because there is persistent pain. The pain persists greater than six weeks of active care. And this is an academics, even if it's non radicular or myelopathic in nature, Even if it's localized. Why? what's going on? Is there a tumor there? Is there a bone frame? the rules are there to protect your patient so you are clearly within and you'd skip it. When was the last time you saw the patient?

Guest Dr: It's been a couple months now.

Dr Studin: You call the patient and you say the following, I need to do a follow up evaluation so I could get your attorney a report, I have to physically evaluate you. When can I see you next? The patient comes in, there are still persistent pain. You call the lawyer, they were getting better. They slid way backwards. I am just not comfortable now I want to order the MRI because I don't know why they slid backwards. And you do it on today's evaluation, not the right months ago. 

 

Dr Studin: Start from the beginning again please.

Guest Dr: an attorney I'd worked with previously, I'm on a couple of cases and he wanted me to work up this couple, they had been in a crash, it was about approximately a year previously. So the man had shoulder surgery, the wife had a like workup, so that's significant Care in the past, they were being referred to physical therapists two hours away. So it's too far of a drive.

Dr Studin: you live in a remote region. So that's important to know, go ahead.

Guest Dr: So I am about an hour from them, so it was better, it was closer. So I said, maybe you can get in and I do a better job with spine pain. So I got them in and did fairly well. Got them even an hour drive. One way to do that, over a couple of months they got in probably 25 visits or so approximately. But the problem was getting the medical records from the previous medical doctor. And so we are sending requisition try to get the report, the problem was that he told me in his intake that he'd had an MRI and so I assumed it was spine because he had of course all this, it was a very severe crash, high speed, totaled car, so now I'm finished their case trying to do their final and so I get them in for the final exam and that's still at that point I haven't got records. So at this point in our state we have like 30 days As chiropractors. Otherwise it's like a board violation to not get records. I assume it's probably similar with the medical doctors. So we get about the point, we're going threaten them. So the problem was I finally get the records and he had shoulder MRIs, never had spine MRIs. So like I can't like finish. So my question for you is, we've talked about diagnosis, prognosis, treatment plan. If I get an MRI a year and a half after the fact, I know will give you age dating and I have a problem with that. So my question is, is there unethical for me to order MRIs purely for getting being able to finish the case?

Dr Studin: Yes, it's unethical, there's two issues that come into play here. Number one with records in every state in the country It is a license violation to withhold records for a coach reading doctor, and this is a primary example, you sends a request, you don't get a response. You give 48 hours. Then you call the doctor's office and say, I sent a request. I'm treating this patient. I need to see the records. I sent the request two days ago. I need them within 24 hours, if you do not have the records sent to you, you call up a third time. I'm letting you know I'm faxing over another request. And in that request, I am letting you know that we're putting you on notice that if we do not have the records in 24 hours, I am reporting you to the state licensure board for a licensure violation. This patient had a serious accident where care was in limbo. I don't know what to do and I can't move forward. And you're delaying necessary care that will be a licensure complaint against your license. Just pair you in, then you have 24 hours, this is my third request and you send it. And then if they don't send it within 24 hours, send the complaint to the state medical board or chiropractic board and CC a copy to them and their fact they know that you weren't kidding. Number two, the only reason you order an image is to satisfy a diagnostic dilemma. do you think that there is a potential spinal cord, root nerve, anatomical issue that needs to be fixed?

Guest Dr: Anatomical nerve root?

Dr Studin: like a herniated disc, a fracture. right now today, does the patient have an unresolved diagnostic dilemma of a radiculopathy or myelopathic components in our world?

Guest Dr: No.

Dr Studin: has pain persistent for greater than six weeks and you don't know why?

Guest Dr: Yes.

Dr Studin: Then there's your question out, this persisted for over a year, and I cannot determine why. Now, if you're opening up a Pandora's box though, because the other issue is, is you close your eyes and go, I know if you get the well, I know I can get them. Well, because you had this same clinical scenario for a year and a half and you did nothing. You're more guilty Then the doctor was holding the records because you actually laid hands on this patient 25 times or maybe the last 15 times thinking that I don't know what's wrong with this patient. How come they're still in pain?

Guest Dr: I would assume it was just biomechanical. So I'm curious.

Dr Studin: The patient has pain. So you're on the witness stand defending your license right now, doctor, the patient has pain for a year and a half. They got better to some degree. But that pain persisted, you assumed that was biomechanical but does not find mechanical issues resolved in a period of time within 18 months, yes or no is a rule.

Guest Dr: Well yeah, but it was about a year.

Dr Studin: So 12 months as a rule, does it usually a baked by then? Yes or no?

Guest Dr: without care?

Dr Studin: with care.

Guest Dr: They didn't had care. That's when it came to me.

Dr Studin: During your 25 visits, how long was that For?

Guest Dr: Two months.

Dr Studin: In that two month time, did the pain of bait go away?

Guest Dr: 100% No.

Dr Studin: Did it go away to the point where you were comfortable after there was nothing else going on? you can't even answer that question appropriately, and this is just you and me. Your clinical will take you just so far, in our world It often is symptomatic, but sometimes it's not that. Then we've got five mechanical failures to look at. But if a patient has pain that persists after six, seven, eight, nine, 10 visits, look, you've how many years you were in the game?

Guest Dr: 31

Dr Studin: I'm in 39 you and I both know the problem with chiropractic is patients get better too quick. They get out of pain too quick and you often don't have a chance to fix their underlying problem. But when they don't get out of pain and you're damn good at what you do, you don't even have to think about treating someone. Do I have that question? You have to want aggressively go after those records and if you can't get the records, order another MRI even without the records in your hands because something's persistent That might've been different from the MRI that they claimed they had six, eight, 12 months. It's unethical to order an MRI just to make a case. Is it very ethical to order an MRI if the pain is persistent and you don't know why.

Guest Dr: Got it now, now the real world. what do I tell? go to the attorney and tell them, I screwed up? What do I, how do I?

Dr Studin: you go to the lawyer and say, I screwed up. Tell the truth. So it shall set you free. The doctor stonewalled; he didn't send me the records. I should've reported them to the licensure board, But when the patients said that he had MRIs, MRIs was of a shoulder, not spine, and I should've aggressively gotten the records or another MRI. But at this stage of the game, the patient has persistent pain and I don't know why. And I want to order an MRI. I want to order it now I want to see what's going on. I feel like something was missed, and you tell them, it's on me. It's not on the other doctor. This is on me because I should have known better. And I tell people the truth, no one's perfect. People appreciate honesty. And if he doesn't want to work with you from here forward because you messed up, it's better than lying And then he finds out later on. That all of a sudden your reputation is destroyed. But you and I are constantly professionals. Some lawyers and coach treating physicians are petty and they won't have the level of maturity We will, and just chalk it up to a learning experience.

Guest Dr: Should I call to tell him I think we should get an MRI this late in the hunt.?

Dr Studin: it is not this late in the game, the patient today has persistent pain. Why? you don't know.

Guest Dr: so you're saying that is okay.

Dr Studin: Yeah, because there is persistent pain. The pain persists greater than six weeks of active care. And this is an academics, even if it's non radicular or myelopathic in nature, Even if it's localized. Why? what's going on? Is there a tumor there? Is there a bone frame? the rules are there to protect your patient so you are clearly within and you'd skip it. When was the last time you saw the patient?

Guest Dr: It's been a couple months now.

Dr Studin: You call the patient and you say the following, I need to do a follow up evaluation so I could get your attorney a report, I have to physically evaluate you. When can I see you next? The patient comes in, there are still persistent pain. You call the lawyer, they were getting better. They slid way backwards. I am just not comfortable now I want to order the MRI because I don't know why they slid backwards. And you do it on today's evaluation, not the right months ago. 

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