Changing Times: Interview with Gary Tarola, DC, DABCO

:dropcap_open:D:dropcap_close:r. Tarola earned a BA degree from Marshall University, 1973 and was a Suma Cum Laude graduate of Palmer College of Chiropractic, 1976. He began private practice in Fogelsville, Lehigh Valley, Pa. in 1976. He obtained Diplomate status in Chiropractic Orthopedics in 1983. He was a post graduate faculty member of several chiropractic colleges. From the late 1980’s through 2005, he lectured extensively across the country on various orthopedic topics and case management protocols. 
tarolaDr. Tarola served as president and chairman of the board of the Pennsylvania Chiropractic Society (PCS). He received Chiropractor of the Year award from the PCS and Senatorial Proclamation of Accomplishments from the Pennsylvania State Senate.  
He was a consultant to the formulation of the Guidelines for Chiropractic Quality Assurance and Practice Parameters and the Council on Chiropractic Guidelines and Practice Parameters. Dr. Tarola has published numerous articles in peer reviewed journals and contributed to chapters in volumes two and three of the text, Principles and Practice of Chiropractic. 
In 2006, Dr. Tarola relocated his practice to the hospital campus of Lehigh Valley Health Network (LVHN), Allentown, PA.  His practice was acquired by Lehigh Valley Physician Group (LVPG), a division of LVHN in May 2012.  Twenty years ago, an idea such as this would have seemed outside the realm of possibility, however today, it appears as one of the potential future realities for  a chiropractor entering practice.  Read what Dr. Tarola had to say in this one on one with The American Chiropractor Magazine, when we discussed his story.
TAC: What kind of practice did you have? Was it a pain-based practice? Was it a wellness type clinic?
Tarola: My practice was and is a fairly typical chiropractic practice. We primarily see patients with back, neck and headache disorders. But we also treat patients with extremity disorders of all types. Both me and my associate have diplomats in Orthopedics and focus on orthopedic conditions. We have seven additional dedicated staff members. The practice sees over 300 patient visits per week with 50-60 new patients per month, most of which are medical referrals. All the staff was hired by LVPG and we still function as we did prior to acquisition. 
TAC: What kind of techniques would you use in your practice? Are there any specific or general types?
Tarola: We use fairly standard chiropractic techniques including various forms of high velocity adjusting and mobilization techniques, drop-table techniques, distraction therapy, pelvic-blocking and myofascial therapy including instrument assisted techniques, and of course exercise instruction. We do a limited amount of nutritional counseling. We use various modalities on a relatively limited basis, including ultrasound, electrical stimulation, and mechanical traction. Most importantly, we communicate with our patients to make sure they understand their condition, have reasonable expectations of recovery and a plan if they do not respond as expected. And we educate them on prevention and lifestyle measures. 
TAC: How did the health network approach you? And what was it about your clinic that made them interested in acquiring it as an asset?
Tarola: I’ve had very good relationships with the medical community in my area for over 25 years. Over the last 10 to 12 years, a prominent spine surgeon, tarola2pain management physician and I have been discussing the concept of a multi-specialty spine program. Because of the health network’s prominent role in serving our community, we decided a number of years ago that it would probably be best to initiate this program through the network.

The idea sat idle for a time and then six years ago it resurfaced and I was enticed to move onto the main hospital campus in preparation for the development of this spine program. I relocated there, but maintained an independent practice. I joined the hospital staff to create this multi-specialty spine program. Once again it was put on hold.
About two years ago, the health network formally accepted the concept of a spine center, decided to fund it, and we began meeting on a regular basis to develop the program. The team included select members of the neurosurgery practice, the pain-management practice, two physiatrists, me and my practice associates, and numerous administrators. We formulated a process, with evidence focused clinical pathways and algorithms, similar to other spine programs such as Texas Back Institute and Jordan Hospital. It was formalized and kicked off in February of this year. At that point, the health network asked me to consider joining. This concept was advocated by many of the medical providers and some administrators I’ve worked with over the years. That’s how those discussions began, in terms of melding my practice into the network. Then through negotiations we turned the concept into a reality.
TAC: It sounds like the relationship has been very cordial and professional?  Would you say that that’s been your experience, that they’ve valued your expertise?
Tarola: No question. My input to the spine program was equal to all others involved. Their approach to me and my practice during the negotiation and acquiring phases was the same and equal to their approach to any other medical practice that has come on board over the years. LVPG includes both primary and specialty practices. The network includes almost 1,000 beds at three hospitalsites, a Level I trauma center, a children’s hospital and numerous outpatient clinics. So it’s a very large and complex organization. But yes, they were professional and equitable.  
TAC: Great. What was it that you had done, or have done, throughout that helped you establish your credibility to the hospital? 

Tarola:Competency in clinical practice, making appropriate referrals and proper communication. It’s important for us as chiropractors to understand our strengths and weaknesses, and the strengths and weaknesses of all other providers that treat the same or similar conditions. All providers have certain things that they do well, certain patients that respond well to their care, and we all have limitations. 
TAC: Absolutely.
tarola3Tarola: It’s important to be able to communicate with all providers on their level, and with confidence. To make it known that you know what you can do and can’t do, you know what their potential is and what their limitations are, and you communicate that in a professional, matter of fact sort of way. They develop an element of respect, then trust and referrals start coming your way. I would say that’s largely how my reputation developed in my community. And then it spreads; it sort of snowballs. Providers talk to other providers.
There are a lot of medical providers that would like to refer patients to chiropractors; they just don’t know whom they can trust for their patients. Many of our patients are also patients of other medical providers, and discuss their experiences. If they get the perception that there was excess or prolonged treatment, inappropriate treatment and unwillingness to communicate, their view of that DC will be tainted.
TAC: How do you establish the limitations of chiropractic care or the care that you give to your patients? How do you demonstrate those limitations to someone that may question you? 
Tarola: Through education, scientific evidence and experience. Response to treatment becomes quite clear to those that pay attention to their own clinical outcomes. The history and physical examination usually provide enough information to determine if a patient is a candidate for the type of treatment we offer. Evidence tells us that if our treatment is going to be effective, we should see a reasonable response within a rather short period. Some studies indicate effectiveness can be predicted after the 1st or 2nd treatment. If our treatment is the best option, we suggest a short trial, 2 to 3 weeks, but also inform them of other viable options, and they decide. If the patient has clinical characteristics that suggest another provider or another form of treatment would be more effective under the circumstances, we inform the patient and initiate the referral. It is important however to know what forms of treatments are available to address the patients immediate needs, and which providers in your community are most proficient at providing those services.
Making appropriate referrals to the appropriate providers at the appropriate times builds a level of trust in those providers that you have the competence to know not only when and who you should treat, but when and whom they should treat. All providers prefer to see patients they will have success with. Referring only difficult cases or patients that have been therapeutically exhausted will not be appreciated or engender trust.
Our practice approaches become known to the people and providers in the community. We are not islands anymore. The patients we see also see other providers, primary care docs as well as specialists. These providers take histories, and patients will reveal their experience with their chiropractor. If they present a history that sounds questionable in terms of the condition the DC was treating, the amount or duration of treatment they received, the kinds of recommendations that were made, a reputation can develop. That kind of information sticks.
TAC: Dr. Tarola, do you send them there with a report, or would you communicate that with the physician that you’re referring them to via phone? Do you communicate at all with that doctor? Or just arrange the appointment?
Tarola: Early on in practice, I would always telephone them and follow up with a report confirming the information that I addressed on the telephone. I tarola4would discuss my assessment of the patient’s condition, treatment provided to that point if any and results of same, why I’m referring and for what, i.e.; evaluation only or evaluation and treatment, and what kind of treatment I felt was appropriate. For those who might want to position themselves similarly, I think you have to start out that way. It’s necessary to communicate as much as possible, make sure the communication is proper, appropriate, and that the terminology used is germane to all healthcare providers. Avoid using chiropractic jargon that no one else would understand. 

I would also always indicate if I intend to continue to follow the patient and manage the patient’s case during and/or after they see the patient. And there was almost never a problem with that, providing it was reasonable and appropriate for the patient.  I would never just transfer patients to medical providers unless I felt I had nothing further to offer. I would always make sure that they knew that I knew what the patient had, that I knew the treatment I could provide and how that would benefit the patient, and that I knew the treatment they could provide and how that would benefit the patient. Nowadays, although I still often communicate in this fashion, my relationship with most providers is such that a referral form is adequate.
TAC: During the first, 15 years, when you were doing a lot more of this, you were sharing research that you were acquiring with your medical providers on the benefits of chiropractic, as well as acknowledging the value that they represent. Would that be accurate?
Tarola: Yes, and still do. Any viable, valid research—on manipulation, or on something germane to their [medical providers] specialty—I forward new published articles or guidelines documents  that pertain to spinal surgery, different types of surgical procedures, surgical rates, pain-management, rehab and other data—whether the research is favorable or unfavorable to their specialty or to mine. It’s important to be objective. I would send a short cover letter and say, “I don’t know if you saw this. I thought it would be of interest to you,” and maybe add some of my own thoughts on the material. 
TAC: How, in your opinion, can your experience with your health network affiliation translate into national success for doctors of chiropractic?
Tarola: I certainly hope that it can serve as somewhat of a model for other chiropractors that have, or are developing these kinds of relationships. It would be my hope that this will be an impetus for other institutions to consider this type of integration. Chiropractic has evolved from a point of isolation 20 years ago and prior, to a point of acceptance, where a good percentage of the medical community and the general public understand the value of our services, and want to integrate these services. In my community, most of our orthopedic groups now have employed chiropractors. Now the largest healthcare organization in the Lehigh Valley has actually acquired a chiropractic practice, which as far as I know, is a national first. There are a number of chiropractors who are on staff or employed at various hospitals, but I am unaware of another one that has actually acquired a practice.
TAC: I haven’t heard of another, so I think you’re right on that. Now, do you see a change in the chiropractors you see coming out versus those chiropractors that may have been around for the last 40 years? How do you see chiropractors differently? 
Tarola: There is a definite shift to an evidence focused approach to practice. Our educational institutions are emphasizing it more and more. Third party payers are essentially requiring it for participation. And there is a plethora of evidence on the things we do most that can’t be ignored. 
TAC: On Pubmed, Google, Medline, the research journals...
Tarola: Everywhere. But I’m concerned that some of our higher institutions are still not training our students adequately enough to develop a scientific mindset. When I say scientific, that does not suggest that our practice be limited to published research. Evidence-based does not mean evidence-only. Much of what all providers do has limited supporting evidence. Evidence-based practice combines the integration of individual clinical expertise, provider experience and patient preferences with the best available evidence. 
TAC: Do you feel that chiropractic’s future is tied to integrative services such as this?
Tarola: Absolutely. It is becoming more and more difficult to survive as a solo practitioner or small group. Third-party payer and government policies and processes make it attractive to be part of a larger institution or group that has some negotiating power. And these institutions are recognizing that they have to offer all available services to stay competitive.
TAC: How would you suggest that other chiropractors position themselves to take advantage of or create these opportunities? You may have already covered this, but to sum it up.
:quoteright_open:Here again however, being integrated into a larger group or institution that has influence and negotiating power might help to mitigate the effect of these trends.:quoteright_close:
Tarola: Develop an expert knowledge base of and demonstrate competence in clinical practice. Study the pertinent literature. Understand our strengths and limitations and that of all other providers that treat the same patients we see. Practice professionally and ethically. Avoid incorporating questionable business processes and therapeutic procedures. Communicate in a logical, professional manner and do it as often as possible. Always look for opportunities where you can communicate with local providers and health care leaders.
TAC: With your current perspective, do you have any thoughts on the changing landscape of national healthcare? How that may affect chiropractors and their roles in patient management? Any perspective on that at all? 
Tarola: Even the hospital institutions don’t know how they will be affected by the new healthcare policies. If chiropractors are included in the process, we’ll have to adapt to the process. It’s pretty clear however, that the trend is more outside oversight. And this is occurring for all providers including hospitals. More and more therapeutic and diagnostic procedures require precertification. That trend is likely to continue. Limitations on treatment frequency, duration and methods will continue to be imposed. Here again however, being integrated into a larger group or institution that has influence and negotiating power might help to mitigate the effect of these trends.
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