“Standards of Care for the Injured”
This consulting session is about my personal standard of care for treating the injured after 35 years of practice. It is not intended to direct the care of your patients in any way and is not reflective of any one patient’s condition. You must decide based upon your own clinical results, what is needed for your patient. This is solely for informational purposes and is not intended to render a medical opinion and/or advice.
I want to make one thing perfectly clear that has a high probability of being 100% accurate; I have made more mistakes than most of you combined in practice. My only saving grace is that I had very good mentors who had an abundance of patience with me and taught me how to render what I believe to be the best care for my patients.
One thing I have learned is that there are different standards of care for different types of patients. In other words, not all patients should be treated the same. At no time, however, have I changed the standard of care for a personal injury patient or a workers' compensation patient because it was “good for the case.” In fact, if an attorney or patient asks you to change your standard of care “to make a case,” then distance yourself from him/her. In fact, run like there is no tomorrow because these are the type of people who along the way will drive you crazy and at the end of the day will be the cause of a significant amount of trouble that YOU will bring upon yourself. There are no exceptions to this rule...ever! The standards of care in practice change based upon practice models accepted by both your state licensure boards and the various research entities that determine the appropriateness of certain diagnostic and treatment modalities based upon the diagnosis of the patient.
Let’s discuss x-ray and MRI when treating the injured. The American College of Radiology (ACR) in their ACR Appropriateness Criteria (2001), published that it is accepted practice to take an immediate x-ray of a traumatically injured body part to rule out fracture and/or other pathology. This is not my opinion, although I concur, and it is not an insurer's opinion, although his/her opinion should never come into play in medical decision making. This is what is called a "legally defensible" position because it is based upon accepted practice standards.
NOTE: Don't get focused on the term "medically," as that is the world we live in according to the lay person. Remember, 95% of the population is on board with the medical community. I would rather be in the game and change the system from the inside than be on the outside with my current 5% and not be able to reach the other 95%.
Standards or "guidelines", as many of you should know, involve a "double-edged sword" as many opinions are biased politically and financially and should be read with open eyes. When you have the opportunity, you should always work within accepted guidelines so long as they meet the needs of your patients. When those guidelines do not, be prepared to defend your position with medically sound rationale that is supported in your documentation.
Regarding MRI, the ACR has ruled that for a chronic patient with pain, it is appropriate to wait until 3 months post conservative care to order an MRI of the affected body part. With the trauma patient, however, an immediate MRI is warranted (they specifically cite the lumbar spine as an example). Most states consider the MRI of the affected area the correct standard of care in diagnosing and, in fact, will hold you to scrutiny should you fail to diagnose an area without the MRI. In fact, without the MRI, if the patient has a problem and you miss it, you stand a very good chance of losing your license and being sued.
Please don’t misinterpret the past statement. I don’t suggest that you practice defensively. In fact, just the opposite. I am suggesting that you take the offensive when diagnosing patients. Be as aggressive as you can to formulate a complete and accurate diagnosis of your patient. Do not fear an insurance company arguing that you are over-utilizing testing. That can never happen so long as your documentation reflects the clinical basis for ordering a test. Then your ordering of any tests are clinically sound and legally defensible.
When I have had a trauma patient (car accident, on-the-job injury, significant slip and fall, etc.), I have always x-rayed the affected body part and if no apparent result was evident on the plain films, I immediately ordered an MRI if there were clinical findings that warranted it. The specific clinical findings are an apparent radiculopathy or myelopathy. These are the pressing reasons for an initial MRI. If you are still not sure of those 2 entities, take the PI Bootcamp (www.TeachDoctors.com) or some other FORMAL course that will teach you to become the best-of-the-best through clinical excellence. You must know the very basics and these 2 clinical scenarios are amongst the very basics!
As an example, if there was cervical pain, a positive foraminal compression test, a loss of range of motion, but x-rays revealed no fracture, I would order an immediate MRI. The result, I would know exactly what was wrong with my patient. No guessing and the person that would be the happiest would be the patient because he/she would now have an accurate diagnosis for his/her problem and would become a much more compliant patient. The end result, more patients get better.
Who wins? The patient gets better and I feel more secure in aggressively treating the patient with a more complete diagnosis. The secondary benefit is that I now have a layer of insulation against licensure issues, providing I have complete documentation. Who is also happy? The lawyer who represents the patient. The truth is, making the lawyer happy is the least (and last) of my concerns. I just want a complete and accurate diagnosis, prognosis and treatment plan. However, if there is a lawyer on the case, he/she would be very happy with you because this is the type of documentation that he/she needs to either move forward on a case or dismiss it because there are no positive findings.
This brings up a side issue. With a lawyer, when appropriate, I tell him/her one of the most valuable pieces of information that I can render; his/her client has no problem. This enables him/her to dismiss the case early in the process and to save countless dollars that would be wasted on a non-fruitful client. A lawyer will appreciate you as much for the "non-finding" as he/she will for significant findings.
Regarding MRI and spine, most professional schools teach that the thoracic spine problems are compensatory. This is not accurate in trauma. I have always ordered MRI’s of the thoracic spine should there be positive clinical findings and pain. Usually, a patient with either a cervical or lumbar problem has concurrent thoracic involvement. I would order MRI's, both cervical and thoracic or lumbar and thoracic based upon symptomatology and clinical findings. Occasionally (approximately 10% of the time), I would MRI all 3 areas, again based upon clinical findings. My unofficial results, over the past 22 years of ordering MRI’s, have been that over 20% of the thoracic spine MRI’s revealed herniations and/or spinal cord involvement. This dramatically changed my treatment protocols with my patients and potentially saved both my patients and myself a lot of unnecessary complications.
Medical specialists are another tool that should be utilized with the trauma patient. Neurologists, orthopedists, pain management specialists and neurosurgeons have a very important role in the care of the patient. The first thing you need to do is to ensure that the doctor is credentialed and has a good reputation in working with fellow doctors. Then…DO NOT REFER ANYONE TO HIM/HER UNTIL you have sat down with the doctor personally and explained the ground rules. Remember, these are your patients. Patients in a healthcare practice are a commodity with respect to getting patients. In healthcare, we do not pay for referrals or use any type of inducements. Therefore, your referral is your commodity and you want to give a referral to help the patient, but you need to tell the specialist that you expect referrals in return, as well. Not one-for-one, but enough for the specialist to let you know that he/she respects you as much as you respect him/her. You also need to let the specialist know that you track your patients and make sure that they end up back in your office and not at different practitioners' offices. It will happen if you are not careful.
The next consultation is a reprint from an article published in The American Chiropractor Magazine in July, 2010, entitled, "Paying MD's for Referrals." Do not let the title fool you. Once read, you will understand. It is a standard of practice in every state for you to refer the patient to the appropriate specialist when clinically indicated. From the lawyer’s prospective, if this is your standard of practice, he/she will think highly of you and consider you to be a doctor that knows how to treat the injured and furthermore, will continue to work with you in the future. I emphasize that is not the reason to refer, but it is a side effect of practicing within the standards of your license.
Should you adhere to the standards of your license and pay careful attention to the documentation, then the legal community will take note over time and you should never have to ask for a referral. Lawyers will seek you out for your level of competency and not because you take them to dinners or ballgames.