Stephen M. Perle, DC, MS
A time to be born, a time to die
A time to plant, a time to reap
A time to kill, a time to heal
A time to laugh, a time to weep
- Lyrics from "Turn! Turn! Turn! (to Everything There Is a Season)"
I think that for all health care providers, chiropractors included, there should be another line: A time to refer, a time to discharge. There are many reasons that people don't make appropriate referrals or appropriately discharge their patients. They may believe that they are more competent than they actually are, and thus erroneously believe they can help the patient. In clinical practice, this is the essence of being an ultracrepidarian (one who professes expertise they do not possess).1
In 1986, I met a podiatrist who might be considered the grandfather of sports podiatry. We talked about orthotics and he told me what company he thought was the best orthotics lab. I ordered a prescribing kit from them. When I got a look at the prescription pad, it asked for all sorts of measurements I didn't remember how to do. (When I was a student, a podiatrist taught part of our extremity examination course.) Given how much I'd forgotten, I decided to instead refer my patients to this sport podiatrist. The result: My patients got better care and far better orthotics than I could provide, and I got referrals in return. I think unless you are the most competent at casting and ordering orthotics in your community (which is possible, depending upon where you practice), a referral is in order.
A former student of mine bought a practice that had every diagnostic bell and whistle one could imagine. He sold the neuroelectrodiagnostic equipment and started referring to the local neurologist. The result: His patients got better diagnostic testing and he got a new referral source, who also recommended this young doctor to the PCPs who referred to the neurologist. His practice grew because he started making more referrals.
I've never owned any equipment for taking radiographs. When I was practicing in New York City, there were just too many radiologists nearby to make it reasonable for me to take films. Plus, I know that a radiologist (chiropractic or medical) is far more competent than I am at reading films.2,3 (This situation may be different in other practices.)
In these cases, the referral is the best (i.e., most ethical) approach for patients. They get better care. I believe the reason that so many in our profession do everything in-house is a backlash of the AMA boycott. If you couldn't have your referral accepted by MDs, hospitals or radiology labs, you needed to perform the service for which you would have referred the patient.
The boycott is long over, so we need to change our behavior. While there are still people in the medical profession who are prejudiced against us, you can always find another professional who will work with you. Remember, I said that my new line to the verse applied to all health care providers:
On the other hand, there are times that medical physicians should be referring to chiropractic physicians for the patient's best interest. If you have been in practice for more than 20 years, you've seen this situation change dramatically, but not enough yet for the patient's best interest. New practice guidelines, such as those from the U.K., will hopefully stimulate more in the medical profession to establish professional referral networks with chiropractors.4 I know quite a few colleagues now who receive hundreds of referrals from MDs every year; obviously those referral sources got the big idea.
In some cases, it may be difficult to refer a patient because of the patient's desires. Patient autonomy is a fundamental and important ethical right. Patients' rights have an associated duty on the doctor's part (in this case it is fidelity) to comply with patients' reasonable expectations.5 However, there are cases when paternalism may be best, as our absolute duty is to prevent harm. A patient's desire to do something harmful cannot mandate we violate our duty to prevent harm if they refuse to undergo a needed test.
I know of a situation where a patient's MRI showed what looked like a disc herniation but also could have been a tumor. The patient was told to return for a MRI with contrast. The patient didn't comply, but the doctor kept treating the patient. What is the doctor's duty? I think that the doctor needs to give the patient two choices: have the requested test or find another chiropractor dumb enough to treat the patient without a definitive diagnosis of what is on the MRI.
Fidelity is complying with a patient's reasonable requests. In this case, it is not a reasonable request to continue to treat the patient until you know if the abnormality on the MRI is a treatable condition - a disc herniation or a potentially life-threatening tumor. It turned out to be a benign tumor that was the etiology of all the patient's complaints, but they suffered needlessly during years of chiropractic treatment, which only kept the pain manageable. Some may not discharge the patient because they want or need the money. This affects us both consciously and unconsciously. This concept of doing anything for money is to quomodocunquize.1
You may have heard the joke: How many chiropractors does it take to change a light bulb? Answer: one, but it takes 30 visits. Where did this come from? Our professional reputation for not discharging patients, which I think was because of our isolation as a profession. As long as chiropractors remained outside of the mainstream, the flow of patients may have been low enough that the only way to make a living was to see the patients longer or institute lifetime maintenance care. This wasn't B..J Palmer's way. As David Seaman discovered, B.J. wrote: "The osteopaths charge by the month. Why do I charge by the week? Because the chiropractic cures many in one or two weeks. It would not be justice to charge such for a full month. Our patients average about two weeks of treatment."6
It is obvious that B.J. knew that there was a time to discharge a patient. Can you hear him singing the song?
References
- Perle SM. "Quomodocunquize, Ultracrepidarian, Boundary Violation." Dynamic Chiropractic, Oct. 12, 2006;24(21).
- Taylor JA, Clopton P, Bosch E, et al. Interpretation of abnormal lumbosacral spine radiographs: a test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic. Spine, 1995;20(10):1147-54.
- de Zoete A, Assendelft WJ, Algra PR, et al. Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists. Spine, Sept. 1, 2002;;27(17):1926-33; discussion 33.
- CG88. Low Back Pain: NICE guideline.
- Perle SM. "Treating With Hi-Fi and Meeting Your Patients' Expectations." Dynamic Chiropractic, March 26, 2009;27(7).
- Seaman D. "A Cure for the Curse of Chiropractic, Part Two." Dynamic Chiropractic, Feb. 12, 2007;25(4).
