Academy of Chiropractic
Quickie Podcast 1284
Narratives 104 N
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
Diagnosing Normal Findings in Final Reports
Dr. Studin: Good morning. What's going on?
Guest: Yes. So when complicated cases, but what about the simple cases where the patient is excellent with treatment? You know he was feeling great after a few weeks, but I said, let's finish the treatment plan. Ligament takes anywhere from six to eight weeks to heal and he did, he was great. He solid. And at the end, I'm going to…two things. What's the best thing to say in these specimens. And then second, what do I put for my diagnosis? Even when I palpated him, assess him, his range of motion is normal. He is segmental. He's moving. Great. So there to be, I feel like to be honest, to put in my diagnosis, I would say patient does not have any diagnosis. He has normalized but I'd always, but I've been putting in the assessment at this time, like modifying at this time, there are no signs of permanent, um, dysfunction and, you know, affecting his quality of life. But anyway, what do we do on those two matters?
Dr. Studin: Okay. So there's two things that come into play here. Number one, diagnosis, and number two, what do you tell the lawyer? Okay. That's question to even ask. So let's handle the second one first, because it's the easiest one. And what you do with the attorney is you call them up and you say, listen, I have your patient Mrs. Jones. And she actually responded incredibly well with care. And she has residuals zero positive tests, zero functional loss. But you sure you want me to put that on a formal report or just leave it alone? And what you telling the lawyer is you got nothing. If he wants to pursue it, that's up to him. You're not going to get this way and screw him by putting it in the formal report. And you're not going to lie in your ENM reports saying, there's a problem. Now it's in the lawyer's hands. The lawyer will appreciate that because now they're in control of the narrative and you're not telling them what to do. You're just going to tell them you're not going to be a part of it. So they have no unrealistic expectations. Now I once said that to a lawyer and he said to me, listen more. I appreciate that, but I've been on the phone with the adjuster and I need something. Give me like a little pinky, 10% impaired, give me something because I can get money out of them. Just give me something. And I said to the guy, I said, listen, I appreciate what you're saying. I said, but there is nothing. And on top of that, I hear you trying to leverage me to get something. And I really didn't like this guy up front. It was much too aggressive for me. I said, I don't think we should work together in the future because I am never going to make something from nothing. And the fact that you're asking me to do that tells me you're not the kind of attorney I want to work with in the future. So we need to be clear about that from a medical perspective. Now, when you first treated the patient, did you diagnose them with strain sprain?
Dr. Studin: Okay. The literature is clear on, it's funny because in the past two or three months, you've been seeing the consults come through about how I'm going through court cases. Let me read, let me pull out a paragraph which is going to help answer this question. This is being published in September, November. It's going to be in the November, um, American chiropractor journal, a magazine, uh, the carrier contended in the court case, um, against a doctor in Florida in federal court. This is state form in federal court. Here's one of their complaints, legitimate treatment plans for patients with soft tissue injuries, such as strains and sprains may involve no treatment at all, because many of these kinds of injuries heal without any intervention or a variety of interventions, um, including medications to reduce inflammation, really pain past what that is inactive, meaning they, they help without any intervention. So here's my answer. First, we must never minimize the word soft tissue, brain, heart lungs, nerves, the reproductive system, and every other critical organ in the human body Fisher.
The carrier is the parents. This way, the courts that can drop as minor what's physiologically the opposite is more so than not true. The mantra of the carrier of personal injury cases have been strained. Sprained injuries are transient and are not serious injuries because they heal while this deceptive defense rhetoric might sway a court. It does not change your physiology or the literature that is verified. The permanency of strain sprain. And this lawsuit appears the author was mined defense lawyers for years by stating these kinds of injuries, quote, heal without intervention unquote, thus perpetuating a public health risk consider that osteoarthritis is the most common joint disorder in the United States. According to the giant and Jordan, uh, con uh, Janet Jordan. Also the doctor in this case, treats whiplash victims, exclusively a whiplash as a form of strain sprain, where physiologically, you cannot have a strain without a sprain.
The muscles must compensate for the impairment of ligamentous function, connect bone to bone. As we will discuss with lash, also known as strain sprain will lead to osteoarthritis if not treated with the best possible outcomes. And that's perpetuate the number one form of joint disorders. And here's the key part for your, for your issue. There were three grades of strains, sprains, and all involved, different degrees of looking the pairings, all referenced grade one includes a partial tear with the ligament going beyond its of physiological limits. Creating the tear grade two involves a greater degree of tearing and immediate loss of function. Swung intended is great to revisit as is an avulsion of the ligament with a total loss of function, physiological ligaments, a credit embryo, logically for fibroblasts as the ligament develops secrets book collagen and elastin, depending upon the tissue is an example of disc has more college as it is a supportive structure.
While an elbow comparatively is great amount of lasted due to the functional requirements of the elbow fibroblasts, right, actor producing both college and adolescent superiority. And when puberty is raised, the fibroblasts become dormant upon trauma and you know, all this stuff, um, upon trauma, the fiber of warrants become activated to now only produce colleges or a stiffer graded tissue. In the case of whiplash, according to Dolan that out of the ligaments heal the characteristically inferior compositional properties compare with normal tissue and remain less efficient than maintaining loads. This type of wound repair with internal scar tissue known as DJs is permanent. This is due to the laying down of non normal ligamentous tissue that will forever adversely affect the function of the joint. Now, um, I could go on and on, but I'm not the point is if you were initially diagnosed, if you would, additionally only diagnose this function and not strain sprain, we couldn't have this conversation, but the fact that you diagnosed strain sprain initially strength spring is still there, but has zero functional sequalae negative functional sequalae. So you diagnose strain sprain because it will repair the cheaper grade of tissue. And it will affect the person maybe 10, 15 years from that. We don't know that, but we do know that we don't know how much so I would write, I would keep my diagnosis of strain sprain, and I would put a comment after the diagnosis section, which says, thanks on paper. You ready?
Hang up. Okay. The patient was initially diagnosed with strain sprain, which is a permanent condition based upon the inability based upon wound repairing and the ability and the inability to heal with normal ligamentous tissue. However calmer. In the case of Mrs. Jones, the amount of tissue damage was minimal as evidenced by the quick recovery to full function, period. This does not mean that sometime in the, in the distant future, she might have some negative sequelae period, no, not period, although that will be determined upon future examinations. The future of that will be determinant upon future functional loss that has yet to be revealed yet to not, not be revealed, which has yet to, um, which is not yet, which is what you do not expect to be realized for quite some time. If at all, there you go. Okay. I don't have no clue what I just said. So you're going to type it up and you're going to send it to me. I know it was really good. I heard the words coming out of my mouth but I can't repeat it. I got to go out of patient waiting.
Guest: That's perfect. Thank you.