The Rules Have Changed

It can be easy to get into a rut, get used to "the way things are" and just keep on practicing the way we have since first hanging out our shingle. Human nature often seeks the path of least resistance – to just "go with the flow." As chiropractors, that type of thinking is professional suicide. We cannot afford to be complacent, comfortable or just "status quo."

I have written several times about this topic. Most recently, I wrote about how we need to be able to justify why we treat a spinal region. I drew the analogy from an encounter with a medical doctor who could not process that medication was not necessary – and then compared that to a chiropractor who will treat full spine "just because." I noted that chiropractors have just as much of an ability to get tunnel vision as our allopathic counterparts. As expected, I had some very negative feedback.

Reading back through my article, I think it is very clear that I did not disparage practicing full spine. There is nothing wrong with practicing full spine, and full spine care definitely has tremendous value. That is my style of practice. What I did do was comment on the changes in the health care paradigm in this country. To quote the president in his recent State of the Union address, "the rules have changed." Whether we like it or not, we have professional, ethical and legal responsibilities, and in today's medical-legal climate, you must be able to objectively document why you chose a certain treatment plan.

The simple reality today is that you need to be able to show clinical findings and a clear clinical rationale for why you treat any 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"? Your philosophy of practice is very different from your legal obligations as a practitioner to validate your care. Many insurers, including Medicare, are now asking for objective documentation. You must be able to clinically defend the care you provide.

As the president also noted in his address: "That world has changed. And for many, the change has been painful." When I graduated, the Internet was a concept. Now the Internet and electronic medical records are the norm. I have a number of friends and colleagues who still practice the way they did 10, 15 or even 20 years ago. Some of them still keep office notes on index cards. Any new graduate will tell you that is not the recognized standard of care.

Philosophy is a good thing, but it does not release us from the responsibilities we have as physicians. You may be comfortable running your practice the same way you did 25 years ago, but that style of practice is not appropriate today. It is true that what we do is complicated, and not always along the same line of thought or acceptance as our allopathic colleagues. However, you may very well need to define the value of your care with "an orthopedic test or whatever mainstream medicine may expect or desire" – that is just the reality of the world we now live in. It is not "selling your soul." It is what is expected of you as a competent physician.

Chiropractors deserve to be recognized as physicians, but that recognition comes with the responsibility of realizing what they can appropriately do. Again, 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. Your philosophy defines how you operate within the framework of today's bigger health care realm. Being a chiropractor does not grant you "diplomatic immunity" from the same responsibilities of any other physician. 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.

It is true that a subluxated region will frequently affect another region of the spine – but if you are going to make that statement, you need to be able to clinically validate it. "Because that's my philosophy" is an empty argument. 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.

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.

It is dangerous to think that because we are chiropractors, we do not need to keep records to the same degree as medical doctors. We must learn to think outside the chiropractic bubble in terms of health care in general. Ultimately, it is the patient we take care of, not the insurance companies, attorneys or other doctors. Whether or not you feel obligated to document your case, responsible patient care mandates it. Chiropractic deserves every bit of respect any other health profession does, but that respect comes with a level of responsibility. 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. As I've said before, be known for offering the highest level of patient care – don't settle for anything less.