Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 27
"Do Not Rely on the Medical Specialist"
I just returned from a lawyer’s office that referred 3 P-IME’s to me. On one of the cases, the lawyer was very concerned and confused about his client. This client, Mrs. Jones, was in an accident 17 months ago, and was still in severe pain, having seen an internist, a chiropractor, a neurologist and a pain management specialist. With the pain management specialist, Mrs. Jones was on her 2nd series of epidural injections to control her unrelenting pain. The patient had been on multiple pain killers orally while concomitantly being adjusted by the chiropractor for 1 year. During that year, the internist evaluated Mrs. Jones 5 times, each for prescriptions, and Mrs. Jones saw the neurologist 3 times, each time resulting in a referral to the pain management specialist.
The chiropractor treated her regularly during the year. His care was to osseously adjust the cervical, thoracic and lumbar spines, utilizing diversified technique. He treated her 3 times a week for the first 2 months, and then 1-2 times a week for the balance of the year. The chiropractor did not evaluate the patient beyond the initial evaluation, as the patient was being evaluated by the internist and the neurologist regularly. Therefore, the chiropractor relied on the reports from those doctors to set the basis for his care. The chiropractor did use a travel card with accurate notes on how the patient felt each visit and the regions he adjusted.
With this brief overview, let’s dissect the chiropractor’s role and actions to see what is going to happen to this doctor. Based upon his standard of care, this doctor is walking the “slippery slope” and it’s only a matter of time until he will be working in Walmart or the Dollar Store (sorry for the sarcasm). First, he is using a travel card, which according to the insurance industry, by itself is a reason for being investigated, as SOAP notes are the easiest target for the insurance industry to prevail in any action against a chiropractor. That is a statement directly from a lawyer who represents the insurance industry’s interests.
This doctor, on his travel card, only records symptoms and the regions adjusted. What happened to the SOAP format that is the standard of every license in every state and territory in the United States? Upon a cursory inspection, he will have licensure issues and more likely than not, if he goes in front a licensure board, his license will be in jeopardy. After reading his notes and having made recommendations in the past to State Education Departments as a result of my political activities, I would have recommended gross misconduct charges to the board. This doctor would likely lose his license for a period of time (usually from 1-2 years, or be on probation depending upon the political pressure to punish “bad” doctors) if this was a first time offense.
While I was in the lawyer’s office reviewing records, I did not have the films at my disposal. However, the patient had an MRI report with 3 herniated discs, one with an inferior extrusion at C4-5. The MRI was performed soon after the trauma and ordered by the internist, prior to the chiropractor starting care. In the internist’s report, he mentioned the herniated discs, but omitted the extrusion. In the neurologist’s report, he reported the herniated discs, but also omitted the extrusion. In the anesthesiologist/pain management’s report, he reported the herniated discs, but omitted the extrusion. Everyone, including the chiropractor was treating the patient’s pain ignoring the cause of her pain. Where does that leave the chiropractor? The answer is, “In a very bad place.” First, his patient looked to him for answers to her health problem and he failed his patient at every level.
The chiropractor, being a doctor, is a primary health care provider, unlike the physical therapist who is a secondary health care provider and works secondary to a prescription in most states. Therefore, the standard of the chiropractor’s license is that he/she must form his/her own prognosis, diagnosis and treatment plan. A doctor in a “disparate profession” has no expertise in determining the standard of the chiropractor’s care plan. If another co-treating chiropractor has evaluated the patient in a timely manner, then the chiropractor may use that evaluation as a basis for care. This is done appropriately in many offices where there are multiple doctors in 1 practice. This holds true in multi-disciplined practices, as well. You cannot rely on an MD’s evaluation for your conclusions, even within the same practice. You can take them under consideration in developing your conclusion, but you must evaluate your patient and render an independent diagnosis, prognosis and treatment plan for your chiropractic care.
In this case, the chiropractor relied on medical doctors, who have no training in chiropractic, to set the standard for his care. It is contraindicated for a chiropractor to adjust a patient with an extruded disc, as this will often lead to further insult of the spinal roots and/or cord. This patient needed an immediate referral to a neurosurgeon for a surgical consultation and should never have been touched by the chiropractor.
I am not even discussing the issues of doctors reading their own films. The radiologist did an outstanding job on reporting the findings in this case. All 3 MD’s, who overlooked the findings, could have to answer to the fact that they overlooked this significant pathological finding. However, at the end of the day, they will be exonerated, as they will claim the patient’s clinical findings did not warrant a surgical consultation and they treated their patient conservatively based upon their findings.
As a side note: These MD’s failed their patient, as well. They ignored the extrusion and although they will have a very good argument, are still exposed to both malpractice and licensure issues. At the very least, this lawyer will not refer to them in the future.
The chiropractor will not be exonerated, as he did not evaluate his patient and commenced treating on a contraindicated clinical finding. He will be held to the standard of not referring the patient for a surgical consultation and will be found guilty of gross misconduct if brought in front of a licensure board. For this he will lose his license for a few years, in most states. He is also exposed to being sued for malpractice for delaying appropriate surgical intervention and potentially creating more harm to his patient. If sued for malpractice, it will likely only cost him his policy if the patient has any permanent issues…if he is lucky. Juries have the ability to award patients more than the doctor’s policy limits and the chiropractor can be personally responsible for the balance, thereby potentially bankrupting him for the balance of his life.
Will all of this happen to this chiropractor?...Maybe or maybe not…on this patient. However, if the chiropractor does not immediately change his standard of care, it’s only a matter of time until some, or the entire above scenario, will happen to him. You can’t keep sticking your head in the sand and hurting patients without the system catching up to you…thankfully. Why?…Because it’s this system that protects the public from “BAD” doctors. This is a bad doctor!
If you are in a multi-doctor clinic and you are the clinic director and have associates working for you, you, too, have the same liability for your employee doctors’ actions. You are responsible for every step of THEIR care, as it is the standard of every state for you to supervise your employees' care and be held equally accountable.
The solution is simple. Evaluate every patient, understand the clinical issues through clinical excellence and practice within the standards for your license. I receive calls daily from doctors on clinical issues. You are not supposed to understand everything. No one does, but you need to be able to get the answer you need to make an accurate clinical decision. Should you have any clinical issues you are not sure of, pick up the phone and ask me. I am only a phone call or e-mail away and can answer most clinical questions pertaining to spinal related trauma. If not, together we will figure it out or call someone who is more expert on the issue.