DOCTORS OF CHIROPRACTIC (DCS) often ask two questions:
“ How can I get doctors to refer to me, not to PTs?”
“ When I send patients for consults with MDs, why do they send them to PTs?”
My answer has provoked intense discussions:
“Maybe it’s not about being against each other, but instead finding opportunities to respect each other’s space.”
Right or wrong, I have my reasons for my answer: It’s been an “us against them” mentality for a very long time. Twenty years ago, physical therapists (PTs) were probably more on the minds of doctors of chiropractic (DCs) than we were on theirs. In fact, I think most PTs were happy to dismiss our profession, with the exception of our ability to diagnose and our portal of entry status. That too is changing. With a bounty of evidence supporting manipulation, and PTs gaining open access and advanced degrees, what used to be our strength is no longer what separates us. What separates us now continues to be DCs’ primary use of, and comfort in, administering manipulation, in contrast to PTs’ advantages found in existing medical relationships, respect and habitual referral patterns.
Our two professions have been able to exist separately for many years. However, with a health care reimbursement system seeking individualized patient care and demanding physician collaboration, the traditional focus on the spine for chiropractors now calls for a multifactorial approach. One therapy alone will not meet the needs of all back patients.
Integrated Care Issues
If you still aren’t in agreement, consider the following facts as they relate to health care’s focus on integrated care, which affects and will continue to affect the chiropractic physician’s bottom line:
• Historical baggage associated with chiropractic is shifting, but it still exists.
From a medical and PT perspective, while we once were the cure-all, we are still split in half with one side decidedly against the medical establishments and another growing side that wants to work with them more. It’s confusing to the outside world — how do people know which side you’re on?
• The lack of referral relationships continues to hurt our profession.
One primary complaint by MDs against our profession stems from their patients who continue to have pain and have been treated by a chiropractor for months with no improvement and, more important, no referrals. It makes us look both incompetent and financially motivated.
• MDs may have a variety of approaches to back pain, but the great majority do utilize physical therapy at some point in the early course of back pain.
With guidelines not embraced, mostly due to lack of awareness, MDs continue to use algorithms based on organizational and personal preferences. This requires each of us to educate them on how to choose among the conservative therapies based on patient presentation.
• If asked, many DCs don’t have a specific MD they work with.
As soon as patients seek MDs on their own, the DC has just been cut out. The MDs will take hold of the case and work it as they see fit. All they see is a failed DC patient, and this is not what we want to communicate.
• PTs rarely have these conflicts.
Our current status within the medical community is especially problematic as PTs incorporate more manipulation, and accountable care organizations (ACOs) look strongly at collaborative care for the greater good of the patient. In this competitive environment, PTs do want it all. Their 2020 vision very clearly states that they want to be the go-to specialist for musculoskeletal issues. Many PTs want nothing to do with DCs and feel that they are capable of offering any advantages to a patient that DCs might offer. I disagree since I don’t feel that most PTs have a strong focus on manipulation nor is that a standardized offering at all PT offices. Chiropractic physicians are very skilled and comfortable with manipulation. For now, we still own it.
DCs and PTs must learn to meet in the middle to understand each other’s skill sets and when they are most appropriate. If a patient has to go to a PT for whatever reason, don’t you want it to be a PT you trust, one who appreciates your skills? Don’t you want to be a part of a collaborative team? Referrals can come not only to and from MDs but to and from PTs as well. If you want medical referrals, it’s mandatory that you be part of the collaborative team and that includes being pro-PT.
Clinical Practice Guidelines
How can we work together? Education is the answer, and the low-back pain clinical guidelines from the American College of Physicians and American Pain Society will help. Here is how:
• Acute low-back pain guidelines for conservative care list only manipulation.1
DCs are the preferred providers of manipulation, thus making DCs the reasonable starting point for acute lower back pain. That’s a reason MDs can grasp if they are educated on the guidelines and the type of care you provide.
• Manipulation is also one option out of several for chronic pain within these same guidelines.
The question is: How do MDs select among them? What triggers an MD to pick PTs for one patient and medication for another? Understanding physicians’ treatment rationale is key to educating them in a way that creates change. It’s a primary reason letters of introduction don’t have the same impact as face-to-face conversations.
• For those who fail conservative care, it’s reasonable to escalate care.
Patients whose pain responds slower than we would like or expect, or who aren’t responding, may still have results when provided a thorough rehabilitative regimen that most DCs simply don’t provide. It may also be time for a medical consultation.
PTs don’t own manipulation, yet most seem to dabble in it, and DCs don’t own rehab, but some may dabble in it. What’s clear is that there is crossover, but each profession still has ownership of the primary features of care they specialize in that are meaningful to patients at different phases of treatment.
It can be assumed that the great majority of back pain patients can regain function from a basic conservative care approach that seeks to limit the need for pharmaceutical interventions, chronicity, catastrophizing, disability and, of course, surgical interventions. However, if conservative care fails, as it will for some patients, it would be very meaningful to surgeons and other pain management specialists to have a well-documented timeline of conservative care. It’s this mentality that will allow DCs to play in the inner circle of integrated care. Indeed, some insurance companies are moving in this direction as well, requiring such trials of care before surgery can even be considered.
For these reasons, it is imperative that the DC build a trusted referral team that understands the scope of care of each provider, when it is best to offer such care and to not eliminate care or providers based on the initials behind their names — we already know how this feels!
There is a time and a place for both DC care and PT care. Is it impossible for our professions to meet in the middle?
1) Chou R et al. Diagnosis and treatment of low-back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med.
Dr. Christina Acampora is the founder of Aligned Methods, which offers online medical marketing courses and resources, and is the author of Marketing Chiropractic to Medical Practices, a 2007 Jones and Bartlett publication. She speaks for chiropractic and university organizations and is a consistent contributor for ACA News. She can be reached at www.alignedmethods.com.