Teaching MDs To Refer to DCs

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By John J. Triano, MA, DC

On June 6-8, 1996, the University of Texas, Medical Branch (UTMB) at Galveston held their second annual "Current Concepts on Surgery of the Spine." During three days of continuing medical education for over 120 orthopedic and neurologic surgeons, four hours of program time was devoted to learning about the appropriate use of chiropractic services.

The conference coordinator, Alexander Hadjipavalou, MD, sought to extend his positive experiences from the referral of patients to chiropractors to that of his medical colleagues.

He is also the principal investigator on a proposal for a large randomized clinical trial for the treatment of chronic and postsurgical back pain patients. Chiropractic is one of the treatment groups to which patients will be randomly assigned if the proposal receives funding.

Dr. Hadjipavalou represents one of a growing number of medical physicians recognizing the value of chiropractic services. Broader affiliation and collaboration between MDs and DCs is hindered by widely held misconceptions of modern chiropractic practice. Medical physicians literally do not know or understand what chiropractors do, nor what to expect when a referral is made.

The chiropractic portion of the UTMB program had four specific aims:

1. The need to familiarize physicians with an understanding of the way in which chiropractors describe the conditions that we treat. Using the common ground of the scientific literature and specifically the degenerative cascade originally developed by Kirkaldy-Willis (1983), the subluxation was described as being an independent or coincident functional disorder often found in association with existing pathology (Triano 1990). Relevance of chiropractic treatment for patients having degenerative and herniated discs, stenosis, sprain/strain injury, and instability was discussed.

2. To dispel the common notion that manipulation of the spine consists of a few simply applied procedures. Description was given of the complexity of clinical decision making required to match the patient's condition with the host of procedural options. Each one requires understanding of the indications for treatment and the detailed manual skill achieved through prolonged study and practice. Biomechanical descriptions (Triano, McGregor, Skogsbergh 1996) were used to illustrate the diversity in types of methods available. Emphasis was made on the interactive roll of manipulation along with exercise, supportive use of physiologic therapeutics and rehabilitation in case management.

3. The role of chiropractic referral as an appropriate means to manage and resolve postsurgical sacroiliac disorders. The third objective follows on the recent emphasis in the medical literature (Dreyfuss 1994, Schwarzer 1995) on sacroiliac disorders. With the appearance of sacroiliac symptoms in up to 63 percent of postsurgical cases, there is an increasing sense of frustration in the medical community.

4. A demonstration of how a chiropractor assesses and treats representative complaints. This was given in answer to the questions of what should be expected when a patient is referred. During a break-out session, five volunteers were examined and adjusted. Each of the volunteers came from the group of conference attendees with current low back and leg complaints. The wide-eyed response of the patients created a comical outcome as they discovered that their adjustments, in addition to being safe and comfortable, resulted in improvement of their function and relief of their pain. Each was counseled on the need to follow-up their single treatment on return to their home community for sustained benefit to be obtained.

None of the participants in the conference expressed an interest in performing manipulation as a part of their practice. In fact, their discovery of the skill necessary to diagnose the patient and to administer the necessary treatment served as a "reality check." Those who attended the demonstration expressed a new found respect for the application of chiropractic and its skills.
Clearly, it is unrealistic for physicians to attempt to learn to perform manipulation based on weekend training. Such an effort is akin to the notion of teaching chiropractors the necessary science and clinical skills to perform an appendectomy over the weekend.

What is desirable, and feasible, is to teach other provider groups how to triage patients needing chiropractic care. This can be achieved by developing trust in the skills, competence and ethics of the chiropractor, and imparting an understanding of the appropriate indications for referral.

The pervasive negative attitudes of many MDs about chiropractic continues to be the barricade to referrals from MDs. Successful expansion of patient access to our services requires that we successfully surmount those obstacles. Appropriate substitution of DCs for medical care delivery for spine-related conditions, will have a significant impact on cost and outcomes of treatment (Angus et al., 1995).

There are numerous advantages to interdisciplinary collaboration and practicing in a multidisciplinary style. They focus on expanded referral base and case mix for the chiropractic practice; and the greater continuity of care for patients that need combined treatments for optimal outcomes.

The AHCPR guidelines laid the groundwork justification for patient referral into the chiropractic office for acute low back pain patients. The more interesting example of enhanced patient referrals that arises from successful multidisciplinary practice is that of access to the postsurgical population of complex, failed back syndrome cases. These are patients who previously were isolated from chiropractic access by nature of being ensnared in the traditional medical net. This represents a whole new population of patients for chiropractic benefits for which services are empowered by the professional and collegial interaction between disciplines.

As you approach MDs in your area, be prepared to answer questions objectively. Offer literature: Mercy guidelines; AHCPR guidelines; Manga report; and RAND's appropriateness panel outcomes. Also include evidence of the interest of medical meetings in learning about appropriate use of chiropractic, such as from the UTMB meeting. These techniques can open the door for continued dialogue and development of a working professional relationship.

The final stage to anchor a strong mutually beneficial collaboration in patient treatment and referral is personal interaction. The DC and MD each must be comfortable with the other. That is best achieved through frequent face-to-face interaction discussing the treatment of patients, exchange of visits to each other's facility to observe doctor-patient interaction, and procedures and outcomes.

The vast majority of medical physicians have absolutely no desire to learn manipulation. As weekend seminars are completely inadequate to produce competence, medical physicians and chiropractors need to develop cooperative, respectful working relationships that will allow each to serve the patient in their respective areas of expertise.

Reference

Angus DE, Auer L, Cloutier JE, Albert T. Sustainable Health Care for Canada, U of Ottawa 1995, 102-104.

Dreyfuss P, Dryer S, Griffin J, et al. Positive sacroiliac screening tests in asymptomatic adults. Spine 1994: 19:1138-43.

Kirkaldy-Willis W. Managing Low Back Pain. Churchill Livingstone, New York, 1983, p75-128.

Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995:20:31-7.

Triano J, McGregor M, Skogsbergh D. Use of chiropractic manipulation in lumbar rehabilitation. Journal of Rehabilitation Research and Development, 1996 (in press).

DC

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