Academy of Chiropractic
Quickie Podcast 1225
Infrastructure 256 I
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
"Fixing an Old Case"
Dr. Studin: So, what was your question again, please?
Guest: So, I've got an old case that I did a follow up on recently and I realized how when I went back through the case how poorly it was managed and I'm just checking to see if there's anything that I can still do to potentially help.
Dr. Studin: Yes. Okay. This is actually an easy one and it's very common. Most doctors, when they first start reading through the consultations, realize that they just mismanaged cases prior and have you fixed it so you can't change what you did obviously, but what you could do was you get the patient in for another re-evaluation and then what you do is you also want to pull old records. So, call the attorney, ask the attorney for any old records that you have because you want to incorporate them and you kind of do a peer review.
Okay. So what you're going to do is you're going to evaluate the patient, you're going to do a major record review, and you're going to evaluate them with what you know today and then you're going to create that wonderful document that you need to do today. I guess remember what the lawyer needs is not what happened in the beginning of the case, but what has persisted after a reasonable course of care has concluded. You follow up. So, whether it's a month after treatment ended, whether it was during treatment a year after treatment, end of, it doesn't matter. All that matters is what has persisted. And that's what the lawyer needs. So, you're going to document what has persistent as of today. And if something is permanent, permanent doesn't mean it only persists for a year or two and then it resolves. Cause that's not permanent. Permanent means it's permanent until you know the death. So, you will be able to document today, tomorrow, next month, next year, the same thing. And over time it theoretically should get worse as the person tries to compensate.
The other thing is a follow up imaging, documents, those things as a myriad of things that document those. So that's what you need to pull out when you do your evaluation. But again, when you want to fix your historical stuff, you can also pull in limitations in range of motion and complaints and functional losses from other doctor's reports that you now are reporting on as well that you are going to be including in your current diagnosis.
Guest: Got it.
Dr. Studin: There's your answer. It's very simple, do you ever in situations when you do the evaluation or have dogs where they find that, you know, like they screwed up diagnoses, they didn't do EMG NCV like they should have, they should have had the MRIs re-read by somebody who can't, by you actually not by someone else, but by you can't get away from your history. It's been memorialized. So, what you need to do is fall on the sword and tell the lawyer the truth. And so, the lawyer, listen, I've gone back to school, I'm the currently being trained, if I had to work with me in this patient two, three years ago, I would never work with me again. And I want to let you know, I'm acknowledging that here's the holes in the case that by the way, have you finished reading the consultations? Yes or no?
Guest: I finished the infrastructure. I'm almost done with the quick consults.
Dr. Studin: Okay. So, you've got five more sections to go. You haven't done any academics. So, we're really still scratching the surface and there's only two things it takes to get done quicker. Long days and sleepless nights. So now is the time. You don't even know what you don't know yet. So, don't have that conversation with the attorney yet. There's this is the attorney requesting a record. Now is when you hire Dr Schoenfeld to write the report for you, to help it, because you know, you're not good at that yet, by the way. Most of them are doctors. Don't write their own reports. Two to three hours. He gets 150 bucks a report. I don't get anything out of it. He has his own business, but you can make more money. You can make more than 150 bucks in three hours.
So it's really a total waste of your time. So, but what he will do based upon his 40 years of experience is he will extrapolate whatever he can from your documentation, and put your best foot forward on paper to minimize the damage because you're not even really aware of what needs to go in and not go in yet. But you've got to do that. Okay, great. So, don't talk to the lawyer yet because even though you're, you're not back in school yet, you're still learning what you've done wrong. You haven't learned what to do right yet. You haven't even gotten to the narrative section. That's where you're going to go here. When you're done with the quick and you start digging into the CV’s narratives, office systems, getting paid, meeting with lawyers, that tells you what to do. The infrastructure tells you from the theoretical perspective what you should be doing. Therefore, you are learning what you did. That was wrong. You haven't even learned what to do. That's correct yet you're getting close.
Guest: Okay. I already kind of screwed up cause I was going through the quickies and all that stuff and I ended up reaching out to her to let her know that I could do a fall rib on. I already did the rebel or the evaluation.
Dr. Studin: Okay. Which is fine. You did the reevaluation now gets Schoenfeld and let him do him or do you report based so he didn't screw up.
Guest: Okay. And is it too late too? Is it too late to triage her out to a cause? She's got persistent post-concussion symptoms.
Dr. Studin: Did you order, what would you order a brain MRI?
Guest: I'm wondering if I should refer to a neuropsycho and the neurologist or not.
Dr. Studin: Well the neurologist you know, is going to look to see if there's bleeding on the brain. Was there any bleeding on the brain?
Guest: No. Nobody tends to be. He tends to work with a lot of GBI in general.
Dr. Studin: But the question is there any bleeding in the brain?
Guest: Okay. I don't think so.
Dr. Studin: You're not qualified to say that because you haven't taken the stroke course. So, if I asked you what would qualify you to think if there were any bleeds? Well, you know, I'm going to put you on the spot. Okay. What would your answer be?
Guest: the MRI didn't show any bleeds of the brain. I'm not qualified district.
Dr. Studin: Yeah, correct, that's the right answer. Okay. Clinically the word is Sudden. If there were sudden headaches, sudden dizziness, sudden diplopia, sudden ringing of the ears, anything sudden would do that when you would consider hematomas in the brain. But the fact that there was a brain MRI and nothing showed, then you're clear, you're golden. Okay. There's nothing to send the patients to the neurologist for. Now a neuropsychic is very clinically applicable and responsible and you can order concussion testing, using the company cognition but let the lawyer know that you're referring the patient out to a neuro psych biggest, there's a post-concussion syndromes and potentially PTSD, post-traumatic stress disorder symptomatology that you're going to be referring to the patients and you're going to be deferring that diagnosis, do not diagnose them with PTSD. Okay?
Dr. Studin: Okay. Let's the neuro psych do that. But you can put it in your notes that based upon post-concussion symptoms and the patient's history, you want to send them to a neuro psych for an evaluation, potential PTSD.
Guest: And then, if they even though I already had a diagnosed prematurely, a ridiculous privacy, is it too late for me to send them out for an EMG? NCV?
Dr. Studin: Do they have radicular symptoms or signs?
Guest: Yeah, she's got weakness in her inner right hand.
Dr. Studin: Did they have a cervical MRI?
Guest: They did.
Dr. Studin: And what did they report?
Guest: they reported, let me go back to it really quick. They reported a C3C4 tiny posterior disc bulge, C4C5 milder, great paracentral disc, osteophyte complex causing mild minimal central stenosis, C5C6 mild disc osteophyte complex causing mild bilateral foraminal narrowing because that's a jet.
Dr. Studin: And that's a general radiologist?
Dr. Studin: Okay. Which means you have to read it yourself.
Dr. Studin: I can actually look at that MRI. Do you have the actual disc or just the report?
Guest: I just have the reports.
Dr. Studin: Get a copy of the gift copy of the image on this, learn how to open it up and you don't know how to use radiant yet, which is a DICOM viewer. I'll teach you how to do that. Just get a copy of the disc and call me, we will go through it together. Ordering an EMG might be appropriate. So why don't you get the disc and you could have that within the next day or so and out of the game tomorrow and Thursday. So, if you could get the disc today in your possession, which is just sending one of your staff members over to the imaging center or picking it up, that would work, call me back, put it in your computer and we’ll do it together, if not Friday afternoon, I'll be able to look at it .I have some family stuff the next two days, but so get the report over to show, well, it's even too premature for Schoenfeld first step. We've got to look at the MRI.
Guest: Got it.
Dr. Studin: get the patient over to a neuro psych. Let the lawyer know.
Guest: Okay, perfect.
Dr. Studin: So, you're doing good. You're doing really everything perfectly.
Guest: I appreciate that. I try.
Dr. Studin: what are the two things does it take to get there quicker - long days and sleepless nights.