In our previous risk management articles we have looked at the importance of making up your mind about the type of physician you want to be. In particular, we've talked about the importance of deciding what type of patients you feel best inclined to care for, and the financial basis on which you want to relate to your patients. We also looked at the value of telephone intake consultations, the ever-increasing need to establish and maintain excellence of quality in the consultations and examinations we perform, and the use of standardized computer documents or forms. We looked at the importance of taking a good case history and we began reviewing the essential postural aspects of the initial examination.
Let us now move on in the essentials of a risk management examination. As in our previous articles, these principles are presented in review form, as we assume all readers are well-versed in what the essential orthopedic and neurological tests are, how they are performed, and their potential diagnostic significance. Keep in mind that we are not trying to turn anyone into a medical doctor, but rather to be the best of the best for our present as well as future patients. As long as we seek excellence in what we do, we don't have to think or be concerned about medical doctors, HMOs or how society perceives us. Everything we do has the potential to sow seeds and bear harvests. If we sow good seeds, they will eventually bear multiple good harvests in our lives. We personally have found that when we attempt to treat every patient as if they were Jesus Christ, we do the best we're capable of and will be rewarded accordingly.
Posture Speaks to Us--Examine from Stem to Stern or Stern to Stem
If the patient's anterior posterior or lateral posture is altered, it tells us of internal malfunctions, just as palpation reveals spinal subluxations, musculoligamentous imbalances, weaknesses, tenderness, rigidity, fixations, hypertrophy or atrophy. If, when you check the mandible, it drops to the left or right, it not only indicates malfunction of the mandible, but very often atlanto-occipital subluxation which is usually on the same side as the mandible drop.
If the pelvis is tilted it can indicate subluxations, anatomical/physiological short leg, muscle imbalances, and/or supination/pronation of the feet. It does pay to examine the patient from stem to stern or stern to stem, for between the head and feet are many stories and indicators of malfunction and the possible need for chiropractic intervention.
The Feet--The Foundation Often Overlooked
Interestingly, in the second-opinion examinations we have been asked to perform for chiropractors, on average 90% of the patients had short legs and pronated and/or supinated feet; however, only one out of every one hundred of those patients was ever prescribed shoe inserts. Even most plaintiff and defense attorneys wonder how patients can hold an adjustment, let alone get well, if after their treatment they continue to get up off the treatment table and walk on feet that are supinated, pronated or continue to have an uncorrected physiological and/or anatomical short leg. The feet should be palpated, especially if the patient is involved in an automobile accident, occupation or an injury that involves the feet. For example, when people are involved in automobile accidents, by reflex they often jam their right foot onto the break pedal and their left foot into the front floor board. If that occurs they can easily injure their feet, but many times their spinal injuries will be to the extent that they don't notice severe pain in their feet. In similar manner, very often in automobile accidents passengers reflexively jam their feet into the floor board, causing injuries to their feet. The same holds true for other injuries to soft tissues and muscles that not only affect other aspects of the body but also the feet.
Don't Rush -- Haste Makes Waste
Far too often there is a rush to treat the patient without a thorough examination. Short cuts are taken, many of which are based on specialized techniques or procedures that have some very good principles but very often encourage a limited examination. All other techniques should complement a basic but thorough chiropractic, postural, orthopedic and neurological work-up.
Document Subjective and Objective Findings
The need for documentation of subjective and objective findings is a vital precursor to further diagnostic testing and treatment. Like any other potentially good thing, it must be appropriated if its value is to be realized. Many technique teachers have encouraged chiropractors to rely solely on what their test technique results tell them. Many discourage or minimize the need for traditional postural, orthopedic and neurological testing, or anterior/posterior and lateral full spine x-rays. Full spine x-rays remain the most objective substantiators of subluxations and other internal problems. The same holds true with postural, orthopedic and neurological re-evaluations; patients should be re-evaluated at regular intervals, leading to a new diagnosis and a new treatment plan. Doing so is essential in the assessment of the patient's progress, and further validates the chiropractic role in health care.
Perform Tests That Best Serve Your Patients
Any time a patient receives chiropractic care without spinal x-rays, the doctor's risk management ratio goes up and the incidence of malpractice increases. In the very near future, the chiropractic profession is going to experience a massive proliferation of malpractice claims filed by malpractice attorneys, their clients and insurance companies who will be attempting to put blame for herniated spinal discs and spinal disc tears on the chiropractor's treatments. We all know that adjustments don't tear or cause spinal disc herniation, but what defense do DCs have if they do not have spinal x-rays, MRI or CT scan, let alone did not take an adequate case history or perform comprehensive postural, orthopedic and neurological examinations or re-examinations?
Laboratory Considerations -- ESR and CRP
Let us not forget the value in utilizing tests such as ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) in the diagnosis and laboratory substantiation of soft-tissue injuries and many other health problems.
The ESR reflects the relationship of red blood cells to plasma composition (increased globulins and fibrinogen). When soft tissues have been compromised, the ESR will be positive because of increased levels of globulins and fibrinogen. ESR is important in (1) validating internal soft-tissue injuries; (2) assisting in laboratory documentation of organ disease, especially when a patient may be complaining of vague symptoms that are not orthopedically or neurologically substantiated; and (3) assisting in monitoring the cause and status of chronic inflammatory conditions.
ESR is typically elevated in patients with breakdown of tissues (localized or systemic acute inflammatory disease); acute infections; gout; carcinoma; nephritis or nephrosis; multiple myeloma and other dysproteinemias; rheumatic disease; coronary thrombosis; and heavy-metal poisoning.
C-reactive protein should always be considered when the ESR is elevated, and/or ordered when patients are experiencing neuromusculoskeletal symptoms.
Blood monitoring should be pursued in both acute and chronic conditions, including immunological inflammatory diseases (autoimmune complex types III and IV). CRP is almost always present in rheumatic fever and rheumatoid arthritis; acute bacterial infections and viral infections; leprosy; active cirrhosis; peritonitis; acute tuberculosis; Guillain-Barre syndrome; where intrauterine contraceptive devices are used; varicella (chicken pox); and scarlet fever.
Chronic Fatigue -- If the CRP and ESR are negative, the physician should consider the possibility of Epstein Barr virus (EBV heterophile-positive).
Early Warning Signs of Predisposition to Degenerative Problems
It is quite common for people who have experienced soft-tissue injuries to develop chronic degenerative changes in the synovia which can appear in the C-reactive protein blood test months and years before the soft-tissue changes become evident on flat-plate x-rays or MRIs. This is of particular importance to chiropractic physicians, because we all see countless soft-tissue injuries that not only will benefit from traditional manipulation, but metabolic care as well. From a medical legal/chiropractic legal perspective, the ESR and CRP are of significance as well. If a practitioner does not draw blood and/or if the practitioner's license does not allow drawing of blood, the patient should be referred to a facility that will perform the laboratory tests that are needed.
The Insurance Industry Is More Opposed to Chiropractic Than Ever
The objective in filing more complaints with boards of examiners or malpractice claims against doctors of chiropractic is (1) to destroy chiropractic; (2) to not pay what would normally be legitimate claims for chiropractic treatment; (3) to make more money for insurance companies, attorneys, litigious patients; and (4) to create hassles, publicly embarrass chiropractors and destroy chiropractic's credibility in the public's eye.
Know Thy Enemy and Don't Be Lulled by Tokenism
Ever-increasing numbers of MDs and medically-oriented persons in the health industry are under financial pressure to reduce costs and improve profit margins, and they'll do anything they can to financially survive. Chiropractic helps billions of people, and it's still the least expensive approach to health care; which means it's draining money from MDs, PTs, hospitals, HMOs and the insurance industry. They don't like it, and it looks like they aren't going to continue to put up with it.
Beware of Wolves in Sheep's Clothing
Medicine is never going to accept chiropractic or chiropractors as equals. We make that statement as people who have probably found more favor in the health industry than any other chiropractor; but still the fact is evident that if the insurance industry had its choice, it wouldn't have a thing to do with chiropractors. Certainly there will be an increase in utilization of chiropractic in multipurpose health clinics and HMOs, but the care dispensed is going to be limited, and chiropractors will be viewed with less status than a PT or massage therapist. Our years of consulting with insurance companies have taught us much, especially about the prevailing negative, deeply entrenched, bigoted attitude regarding chiropractic. Every insurance company has a fraud unit which exists to save money. Chiropractic is high on the hit list. Inadequate and sloppy records are the first signal to claims handlers to turn the doctor over for investigation by the company's fraud unit.
Chiropractic always has and always will be at its strongest as a separate and independent profession. Once you join your adversary you become like them; chiropractic cannot survive in that mode. What we say is sobering, but not without love. We fully realize that we are to love God and our fellow man, but we cannot survive if we attempt to deny the reality of the generational hatred and bigotry of medicine and the health industry toward chiropractic. The reality is that it appears that MDs, HMOs and hospitals that seem to be opening their doors to us, are those that see our potential to bring more revenue to them and nothing more. Once they have used us as their marketing tool and leaned special treatment procedures from us we will be cast off like so many others who have attempted to align themselves with medicine.
We Have a Brighter Future Outside of Medicine
We have a far brighter future without being considered one of the "good old girls or boys" by medicine, than we do as part of them. Let us love the medical profession as a respected adversary and refer our patients to them when necessary, but be forewarned not to make covenants with them. Any DC who looks to MDs as a source for referrals is in for some hard lessons. The best referral is from a person who got well from chiropractic care. From a personal perspective, we attempt to live our lives based on the two great commandments, and we cannot think of any medical doctor or insurance company that we dislike -- they have their place, and it's not in the graveyard as B.J. believed. We all are called to love, even those who knowingly dislike us, but still we have a job to do and we believe that every chiropractor is called by divine appointment to continue to expand the gospel of natural, drugless, surgery-free living. Let us do what we can to love all humankind and do unto others as we would have them do unto us, even if at times we have to do so by faith.
Do Your Job and Charge for What You Do
If you do what your chiropractic college has educated you to do, and attend balanced postgraduate seminars, you have both the best defense and the best offense. If someone makes a complaint against you, your records should prove that you performed the customary tests that the patient's symptoms indicated. If you don't do your job, they've got you in a position you won't like. In 99% of all cases that we've reviewed of malpractice and complaints filed by patients, attorneys and insurance companies, we've found that the majority could have been avoided if the doctor of chiropractic had conducted and documented proper consultation and thorough examination, re-evaluations, diagnosis and treatment plans.
The majority of the files we've reviewed also show that the fees chiropractors charge for services rendered are low in comparison to other health care providers. Overall, chiropractors are selling themselves, their products, and their services far short of their true value. This is common knowledge in the health insurance industry, but apparently the chiropractors don't know it.
Jerry Lalla, DC
Diane Lalla, CA
Roseville Minnesota
glalla-greatphysician.com
www.greatphysician.com
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