Things I Have Learned: A Matter of Perspective

Everyone has a practice paradigm; you can't be in practice without one. How you think - your perspective - affects how you process a patient's clinical information and lay out a plan of care. Chiropractors often treat from a focus of restoring spinal integrity to normalize structure and nerve function to promote optimal health. Allopathic physicians tend to approach the body more mechanistically and use tools like medications to modify the physiology, or surgery to force a correction. While a personal philosophy is important, do not let that philosophy consume you so much that you forget to act in the best interest of the patient.

As an example, I can share a recent visit I had to a gastroenterologist. Several years ago, I suffered a Grade IV ulcer of the esophagus. At the time, I had no choice but to go on Nexium. On follow-up the ulcer had healed, my prescription ran out, and I carried on with life. It is now five years later and my family doc (a personal friend) has recommended I go for a follow-up endoscopy. The consult with the gastroenterologist went something like this:

GastroGuy: "So, you have reflux."

Me: "No - I had an ulcer a few years ago."

GastroGuy: "Well, you must taste acid in the back of your throat."

Me: "No."

GastroGuy: "OK, so the Nexium is working."

Me: "No - I haven't taken Nexium since my script ran out a few years ago."

GastroGuy: "That's not possible - if you had an ulcer, you have to have reflux. If you don't take Nexium the ulcer will come back."

The debate continued for a few more minutes, and then we did the endoscopy. All was clear - no ulcer. As he got up to leave, GastroGuy handed me an updated script for a year's supply of Nexium.

So, he postulated that I had to have Nexium and if I didn't take it, I would surely have an ulcer. Yet his own study showed the contrary. It was inconceivable to him that I could exist without a daily dosage of Nexium. He could not - or would not - explain why I didn't have an ulcer without having taken medication for several years.

As another example, a good friend of mine just took her 1-year-old son for an update with the pediatrician. He has had good, regular chiropractic care, and he is breast-fed, but has suffered several ear infections. The pediatrician stated: "I don't even need to look in his ears to tell you he is going to need tubes put in." To this doc, surgical intervention was the only possible treatment option.

Now, don't think I am going to use this to only bash MDs. Chiropractors have just as much of an ability to get tunnel vision. At a recent workers' compensation meeting, the concept of treating the area of injury was discussed. The conversation went something like this:

Me: "By the rules of the state workers' compensation model, you can only treat the identified area of injury."

ChiroGuy: "But I practice full spine - if they hurt their lower back, I have to treat the neck, too."

Me: "Can you validate an injury to the neck?"

ChiroGuy: "I practice full spine - I have to treat the full spine."

Me: "Can you document a neck problem associated with the lower back injury?"

ChiroGuy: "Why would I have to do that if I practice full spine?"

I hope you can see the fallacy in that line of thinking. The doctor's philosophy completely overtook his ability to even consider a reason for what he did. Now, don't think I am trying to bash full-spine practitioners, and I am certainly not throwing a sales pitch for Nexium. I think my point is clear. Take the data at hand and interpret it objectively. You need to be able to show clinical findings and a clear clinical rationale for why you treat an area of the spine. It can certainly be argued that treating the neck is appropriate when addressing a lower back complaint - but are you able to explain your rationale for doing so, more than just saying, "Because I have a full spine philosophy"? Many insurers, including Medicare, are now asking for objective documentation. You must be able to clinically defend the care you provide.

Chiropractors deserve to be recognized as physicians, but that recognition comes with the responsibility of realizing what they can appropriately do. Further, in today's medical-legal climate you must be able to objectively document why you chose a certain treatment plan. Philosophical ideology is good - but it is not an adequate legal argument. Treating an asymptomatic neck "because I practice full spine" makes about as much sense as prescribing Nexium to treat an ulcer that is not there. Make sure you know what you are treating, and why. You must be able to show a thought process for the care you render; anything less may be construed as reckless and negligent.

There is no one single modality that will meet the needs of every patient. Given your personal experiences, you may have developed strong preferences, and there is absolutely nothing wrong with that. You may or may not like this or that technique; you may not wish to pursue some specialized therapy; but you must make sure you are open minded enough to recognize when a patient may not be responding to your plan of care, and when you should be referring for co-management with a competent para-practitioner.

Moreover, patients are different and individual patient needs are different, so every patient should be evaluated and treated on the grounds of what is best for them. You should recommend what you feel to be the most appropriate care plan, regardless of what their insurance covers. If your care is limited by a plan contract, or by a patient's choice to only receive services covered by their plan, you are still obligated to share with them your recommendations and document why those treatments are not being pursued.

Make sure you know and understand the benefits and limitations of the procedures you offer. Make sure your patients know that you are working to meet their needs. Be known for offering the highest level of patient care - don't settle for anything less.