This article will wind up the third (and final) year of my column here with American Chiropractor. I’ve used a lot of ink in the past thirty five issues dealing with various aspects of postural rehabilitation, so I’d like to take this opportunity to tie up just a few loose ends relevant to this month’s emphasis on diagnostics.
Creating an Accurate Diagnosis, Prognosis & Treatment Plan through Clinical Excellence Is the Key to Profitability in Your Practice
by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP
Mrs. Jones enters your office complaining of escalating chronic neck pain with mild left arm pain that has been present for months. After a complete history, you perform a thorough evaluation and there is a mildly positive foraminal compression test, 4/5 in the biceps on the left and mildly diminished reflexes at C5 on the left. You order a cervical spine X-ray series of an AP, lateral and AP open mouth, and begin treating your patient. This is a typical scenario in most chiropractors’ offices nationally.
We, as chiropractors, treat our patients with high velocity thrusts. Some are gentler than others but, to the general public and the Chiropractic Board of Examiners in our states’ education departments, that is what we do. These high velocity thrusts are what corrects the subluxation and allows our patients to get well. In treating these patients, we have a covenant with our licensure board that is the basis of our license: to create an accurate diagnosis, prognosis and treatment plan prior to delivering our treatment, the adjustments and ancillary therapies. The licensure boards, nationally, have a covenant with the people in each state and that is to protect them through strict regulation of doctors.
As a result, our licenses are not a “right,” as freedom, or the right of free speech, as outlined in the Bill of Rights. Our license is a privilege and we have to practice within that standard or we lose that privilege. There is little leeway with many licensure boards regarding your standard of practice.
Most, if not all, adverse licensure issues are triggered by complaints from injured parties or insurance companies and the ensuing investigation by the board. In this instance, let’s consider a complaint from the patient. In the above clinical scenario, was clinical excellence practiced to create an accurate diagnosis, prognosis and treatment plan?
The history and examination were consistent and you now consider delivering high velocity adjustments to the patient’s cervical spine. The next decision is imaging. In consideration of imaging, the views taken have to rule out all forms of osseous pathology and determinate structural deviations in creating a final diagnosis, prognosis and treatment plan. You choose your standard three views and see nothing regarding pathology.
The next question that arises is, “What if there is spondylosis or a tumor, such as a osteoblastoma, in the foramen?” Can you see these and other space occupying lesions on your AP, lateral and AP open mouth? The answer is no. Is it likely that there is a tumor creating the symptoms? No.
Can there be a tumor? Yes. Spondylosis is highly likely, depending upon the age of your patient and, chances are, there is degeneration.
Does it change your prognosis, diagnosis and treatment plan if these pathologies appear on film? Yes.
Therefore, by omitting potentially clinically indicated views, you are exposing your patient to perhaps a contraindicated procedure. What are you doing by taking the additional X-ray views? You are protecting your patient by creating an accurate prognosis, diagnosis and treatment plan. You are protecting your license by creating an accurate prognosis, diagnosis and treatment plan and, the least important reason, that emphatically is not a reason at all to take
additional views. You are making more money for the right reasons: clinical excellence in a conservative environment.
The same patient has been ordered to be treated three times a week for four weeks, followed by a re-evaluation. Mrs. Jones, after two weeks, is feeling better, and misses one visit. Your staff is instructed to call her and make sure she is in for her next visit. What about the visit she missed? Doesn’t she have to make that up?
The problem with the patient recall log is just that. You are recalling your patient to continue their treatment plan, as outlined by the doctor. Mrs. Jones needs to have her spine stabilized, is required to be cared for three times per week and must make up that missed visit. If she doesn’t, that week she is receiving two-thirds of her care and will not get the expected results. This should be explained and outlined in a written report of findings at the onset of care (a different topic for a different article).
Based upon clinical excellence, you have taken every step to ensure an accurate prognosis, diagnosis and treatment plan. Therefore, to ensure clinical excellence, the treatment plan must be adhered to by making up missed visits either later in the same week or with an additional visit the following week. Chiropractic’s success is based on the cumulative effect of the corrective care of the adjustment.
If the patient doesn’t make up the visit, are they compromising their care? Yes.
If they make it up, will they get better quicker? Yes.
If they make the visit up, will you make more money? Yes.
Do you ensure compliance of treatment plans for financial gain? Another emphatic, “No.”
These are but two examples of how practicing with clinical excellence renders a profitable scenario for the right reasons in a practice. Anything less and you risk not practicing within the standard of your license.
Dr. Mark Studin is the President of CMCS Management which offers the Lawyers Marketing Program, Family/MD Marketing Program and Compliance Auditing services. He can be contacted at