Things I Have Learned: Why Do You Do What You Do?

Recently, I was listening to a lecture on how to build up a cash practice. As the speaker laid out his presentation, he read through a list of several indicators to show how the chiropractic profession was in distress: Enrollment at chiropractic colleges is down, chiropractic student loan default rates are up, etc. Another point he made was that chiropractic colleges are now offering courses in other disciplines, such as acupuncture, massage and herbology. To the speaker, this was a sure sign that practitioners are looking away from chiropractic to other options to make it in business today.

I guess if the only reason the schools are offering other courses is to boost enrollment, then that is a sign of a problem. Perhaps I'm being naïve, but I can't believe the only reason courses in other health disciplines are offered is because chiropractors need to learn something that will bring in the money. Sure, we all want to make money - who doesn't want to be successful? This issue raises some interesting questions: Why are such courses out there and why would chiropractors (or future chiropractors) want to take them? Why do chiropractors need to look beyond manipulation for revenue? Do they do these other procedures just to pad a bill, to make ends meet? Why would you do therapies or other modalities in your office besides manipulation?

These questions have many different answers - but I think they are all good questions. First, I will state that I am a mixer - I love doing different therapies. I personally believe my care is more effective when I integrate other techniques. I have good friends who are "straights" and that works for them. There is a philosophy to chiropractic. and different doctors have differing thoughts on appropriate patient care. Beyond that philosophy, however, must be a rationale for the care you provide a patient. You must know why you prescribe the care that you give (or why you did not give a particular treatment). As I have said before, the chiropractic profession deserves every bit of respect any other health profession does, but that respect comes with a level of responsibility. Chiropractors are doctors, and doctors are responsible for what happens to their patients.

When a patient presents to your office with a hot low back, you need to decide what to do. Standard of care dictates that you obtain a thorough history and perform at least a focused evaluation. If there is a question of trauma or injury, radiographs typically are the next step. Given this information, you would then lay out a treatment plan. Will you adjust the patient right away? Will you do EMS with ice packs? Will you do flexion-distraction techniques? We have all had these patients in our office and we all have an idea of what we would do; but the more important question to answer is: Why would we do that?

Will you do ice to calm spasm and pain? Maybe you will choose not to because the patient can't tolerate cold. Will you do flexion-distraction techniques to work the disc space? Perhaps the patient will be in too much spasm to tolerate that therapy. Whatever you do for that patient and whatever the reason, you must be able to justify your choice of treatment (and, of course, document your plan of care).

I once heard a practice management consultant say that if you were contracted with an insurance company and that company covered certain modalities, then you were indirectly bound by your contract with that company to provide those therapies on every patient who came to you with that plan - regardless of whether they needed it. Obviously, his goal was to generate revenue. In the real world, this suggestion is inappropriate - insurance coverage is not a justifiable reason to perform a therapy modality on a patient. Patients often will need care not covered by their insurance, be it a therapy, chiropractic care or a surgical procedure. It's your responsibility as a health care provider to explain to them the cause of their problem and what you recommend to do to fix that problem. What patients choose to do for care is their choice. Do not let insurance coverage dictate your patient care. That is a dangerous game with a no-win ending! If you recommend a plan of care and the patient declines, then it was the patient's choice. Don't assume a care plan based on "what the insurance company said."

I began to study acupuncture within a few months after graduating from chiropractic college. I was still so green in chiropractic that I didn't quite know how I wanted to develop or style my practice. At the time, all I knew was that I needed to learn acupuncture. My drive to learn acupuncture as an adjunct to my chiropractic practice came from one of those "life-changing" experiences during my preceptorship. On that particular afternoon, a mother walked in, carrying her 11-year-old daughter. She needed to see the doctor because the child was having a "bad spell." The child had cerebral palsy and had almost no control of her arms or legs. I didn't know what was coming as I helped get her back to the treatment room.

After about 15 minutes of some gentle cranial work and meridian-style laser acupuncture, I saw this girl raise herself up off the table and walk down the hall. She still had CP, but she was walking by herself. That is the kind of miracle everyone needs to see early on in their chiropractic experience to realize the incredible power of this healing art.

After the girl and her mother left, the doctor looked me dead in the eye and told me, "You have seen what chiropractic and acupuncture can do when they are used together. You cannot ignore that there is more you can do for your patients. If you choose not to pursue integrating acupuncture, find someone you can work with who does. You have an ethical responsibility to provide the best options of care for your patients." Heavy words, but they were true.

So, what is to be learned from all of this? First, there are a lot of options for patient care. There is no one single modality that will meet the needs of every patient. Given your personal experiences, you may or may not like this or that technique. You may not wish to pursue certain specialized therapies. 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. Next, 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. Finally, you should recommend what you feel to be the most appropriate care plan, regardless of the insurance coverage. If your care is limited by a plan contract or by a patient's choice to only receive services covered by their plan, you still are obligated to share with them your recommendations and document why those treatments are not being pursued. Make sure you know why you do the procedures you do. Make sure your patients know you are working to meet their needs. Be known for offering the highest level of patient care. Don't settle for anything less.