The patient enters your office and has significant pain radiating into an extremity. Being responsible, you adopt the policy of the insurers and treat the patient conservatively for 4-8 weeks and the pain doesn’t diminish; you then refer the patient to the imaging company for an MRI.
In the report, there are minimal findings, so you continue to treat with marginal results. After a few weeks, you refer to an orthopedist who, in turn, refers to a neurosurgeon, who eventually orders another MRI prior to surgery. At first, you get angry because you are out of the loop; secondly, you feel, over time, the patient could have responded to your care; and, finally, you lose sleep worrying about a malpractice suit over something you did or didn’t do.
This is the litany of emotions that thousands of us have gone through because we were not in control as a result of our ignorance of anything other than clinical evaluations, spinal X-rays, some electrodiagnostics and adjustments.
Being the best-of-the-best in chiropractic includes your ability to understand the innate component of the adjustment and/or the joints’ ability to function normally once put in the proper position. These basics make chiropractic unique and are the foundation for patients getting well in a way no other healing discipline can compete.
However, this is 2009 and, with advanced technology, we can see more, understand more and do more in triaging the severe, mild and sub-acute patients. The tool is advanced imaging, specifically MRI and, when contraindicated, 3-D CAT scans. Regarding technology, a 1-Tesla MRI machine will soon be released and will be capable of scanning patients with pacemakers
Not every condition responds to chiropractic care, and knowing when to refer will affect the outcome of your patients’ care positively, protect your license, and give you many peaceful nights of sleep. In addition, it will grow your practice over time, better than any marketing scheme you can devise.
The reason your practice will grow is twofold. First, your patients will recognize that you have found the cause of their problem, especially if surgery is necessary; you will be the reason that they got better and will tell everyone they know. Secondly, the medical community will recognize you as being the best, based upon your referrals, documentation, triaging and your clinical conclusions and will engage professionally with you, resulting in dialogue and cross referrals.
You will become part of the health care team instead of someone on the "outside looking in," based upon your clinical abilities or lack thereof. This has been quoted to me by many medical specialists through the years. There is validity to negative medical comments, if the patient has a condition beyond chiropractic care and you treat them at their peril. Although it should be an indictment against the individual doctor for not triaging the patient properly, it becomes an indictment against chiropractic; fair or not.
The truth is that not one health care provider can help every patient. Advanced technology and the knowledge of how to utilize it is often the difference in triaging the patient accurately.
Whether you practice in a subluxation or musculoskeletal model, the parameters for triaging the patient remain constant. I strongly recommend that, if the patient exhibits radicular or myelopathic clinical findings, an MRI be ordered to determine the nature of the lesion, prior to commencing aggressive care. There are many models and insurance industry parameters that do not agree. However, my paradigm is simple: If you do not know, you do not touch.
The flow of care is diagnosis, prognosis and then creating and executing your treatment plan.
A radiculopathic or myelopathic finding indicates that there is a space, occupying lesion on the spinal cord or nerve root and will dramatically change your treatment plan based upon the clinical presentation of that lesion.
Being in control of your patient has two components. You need to know the full extent of the cord and/or root lesion when they present clinically and need an MRI; and, secondly, you need to be able to interpret the MRI.
The only time in my thirty years of practice where I had a significant problem was when the medical specialist misdiagnosed the patient’s MRI findings and I accepted it as gospel. Since then, I have learned to read MRI’s, realizing that the general radiologist error rate on my patients was upwards of 40 percent. Neuroradiologists and neurosurgeons report the error rate over 70 percent.
There are courses that can teach you how to read MRI’s and I strongly urge you to gain control of your patients and your practice by doing so. As technology advances, the information gained, becomes central to the chiropractor in creating an accurate diagnosis, prognosis and treatment plan.
Next month, I will discuss how to create a chiropractic team that includes those medical specialists, while maintaining the control over your patients, even if surgery is indicated. That subtle shift is also the key to unlimited referrals from the medical community and all it takes is becoming the best-of-the-best at what you do.