RECENTLY, I HAD THE PRIVILEGE of attending the Nebraska Chiropractic Physician’s Association meeting. At that meeting, Dr. Stephen Lazoritz spoke about his experience working with doctors of chiropractic in the Nebraska Medicaid system. I was so impressed that I asked to set up an interview.
Dr. Greenstein: Can you provide some background on how you got started in medicine?
Dr. Lazoritz: I grew up in Brooklyn, N.Y. and I wanted to get out of the city as quickly as possible, so I went to college in Buffalo, N.Y. and finished my medical school at State University of New York at Buffalo. I then went into the Navy and did my residency at Naval Hospital in Portsmouth, Va., first as a pediatrician at a Naval Base in Orlando, Fla. and then teaching at the Military Medical School in Bethesda, Md. When I finished, I went into practice, teaching pediatrics in Buffalo. And that’s when I became fully occupied in the area of child abuse.
My practice was either general pediatrics or caring for abused children. I did that for several years, then moved to Milwaukee where I became the medical director of the Child Protection Center. I did that for eight years, and being burned out, decided to move into administration in Omaha as VP of medical affairs at the Children’s Hospital. I did some consulting work in physician communication, and managing disruptive physician behavior.
I worked for the Department of the Defense doing medical evaluations, and also worked in utilization review for several years. I retired from the government and started my new life as the network medical director for Arbor Health Plan.
Jay Greenstein: Arbor Health Plan is the Medicaid system in Nebraska?
Dr. Lazoritz: How Medicaid works is that the state contracts with managed care organizations, and in Nebraska, there are 83 rural counties. There are two companies that serve them, Arbor is one. And then, in the 10 urban counties, there are also two managed care organizations. The state contracts with us to provide recipients of Medicaid with the best possible care.
Jay Greenstein: What got you into pediatrics?
Dr. Lazoritz: I always felt kids to be the future of our society and if we have kids who are abused and poorly cared for, that’s what the future of our society is. Too many children are affected by child abuse, and I thought it was a way to really make an impact.
Jay Greenstein: What is the biggest challenge you had to overcome in the area of child abuse?
Dr. Lazoritz: I coauthored a book about a child who was abused in 1874. The book is entitled Out of the Darkness and is based on a child named Mary Ellen. It was the first case where a child was taken from the home and brought to court because of child abuse. The great lesson I learned was that it takes one person helping one child at a time. And because of that case in 1874, the whole child protection movement in this country started.
Jay Greenstein: Why do you think the problem of child abuse is so immense?
Dr. Lazoritz: I’ve asked myself that question a lot, and the answer is, I have no idea. I think that there is a generational cycle where kids get abused, and when they grow up, they know nothing else. They know neglect or abuse and it perpetuates itself, and so as a society, we have to invest in breaking this cycle.
One of the great child advocates, Henry Kempe said, “Parents who abuse their children love their children but they don’t love them well,” and I think that’s true. I’ve met thousands of parents who abuse their children, and I think it’s a minority that doesn’t love their children. They just don’t know how to deal with them.
Jay Greenstein: What kind of interactions have you had with doctors of chiropractic (DCs) and their patients?
Dr. Lazoritz: As a pediatrician, I didn’t have much contact with chiropractors. Sometimes a mother or father would let slip that they took their child to the chiropractor and I would shake my head and say, “Why would you do something like that?” Clearly, it was out of ignorance.
Jay Greenstein: Talk about your personal experience of being a chiropractic patient?
Dr. Lazoritz: Years ago, I had severe back pain. A relative had gone to a chiropractor, got relief and it was a positive experience. I went to the neurosurgeon who had little to offer me other than pain pills or a scalpel. So when I was having a lot of pain, I found a chiropractor who I really liked. He was honest with me, explained to me what chiropractic is, and it helped.
A lot of people feel like me that they don’t want to take narcotics, they don’t want surgery. They want something else. I had spine surgery back in the ‘80s and my problems were not solved. This isn’t unusual, that after having surgery you can go into a downward spiral of spinal pain.
At one point, the chiropractor referred me to an orthopedic surgeon. His practice includes a chiropractor, so I learned there are physicians that embrace chiropractic. That’s how I look at it now. Chiropractors are part of the medical team.
Jay Greenstein: The chiropractor that you had seen for your severe back pain was Dr. Jeremiah Rethwisch?
Dr. Lazoritz: Yes, and my wife, three of my daughters, and one of my sons have seen him. I am so impressed with him that I invited him to be part of Arbor’s quality-of-care process
Jay Greenstein: Has being a chiropractic patient influenced your clinical decision making?
Dr. Lazoritz: Absolutely. I’m very open to chiropractic as a mode of therapy. From my experience with Dr. Rethwisch, I found that chiropractic is intrinsically educational. That is part of chiropractic — the education process — not just try and take away the pain, but to try to make me well. That’s the difference between chiropractic and allopathic care. I take away pain by giving narcotics, but making me well is a different concept.
Jay Greenstein: What is your opinion of the current research base for chiropractic and did it surprise you that we have evidence-based guidelines?
Dr. Lazoritz: It surprised me and I was very impressed. The first guidelines were the consensus statement on pediatric chiropractic, and I think most pediatricians if they read that would be impressed to see that DCs do what medical doctors do. They look at the evidence, and try to form best practices.
I was very gratified when I started seeing some of the chiropractic records that come through; about the absence of some of the red flags and that’s one of the items in the consensus statement, looking for red flags and treating pediatric patients. When chiropractors practice according to best practices, they enhance their credibility.
Jay Greenstein: The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) is the organization that works to bring evidence into practice. The profession is very fortunate to have this organization, and especially researchers like Dr. Cheryl Hawk.
Dr. Lazoritz: Another important aspect is the best practice in health promotion, disease prevention and wellness. I thought that was very impressive of having alignment with regard to screenings. Most of the same screenings that medical doctors do are advocated in your profession’s consensus statement.
In Nebraska, the state’s Medicaid program includes chiropractic care as a covered benefit. Arbor’s part of a family of health plans, AmeriHealth Caritas, and three of its Pennsylvania plans, as well as its plans in Florida, Indiana, Louisiana and South Carolina, also include it.
One of the benefits of working with a company like Arbor that is part of a family of companies is we share information. I have shared my opinions on chiropractic, and I think some of the network medical directors have.
Jay Greenstein: What benefits have you seen in working with DCs?
Dr. Lazoritz: Nebraska has many towns that the only practitioner is a chiropractor. Chiropractic is something well accepted, well integrated in Nebraska, but I don’t think the medical profession has accepted them as colleagues as well as can be. My vision is that if patients go to a chiropractor, they have the DC send records to their medical doctor — primary care physician — and vice-versa, so they’re collaborating. One of the real problems is when you don’t refer because you think you’re going to lose the patient. That’s when the patient suffers.
Jay Greenstein: What are the areas you think the chiropractic profession could improve upon?
Dr. Lazoritz: Having reviewed medical records for years, when I look at the chiropractic documentation it’s like reading another language sometimes, especially the terms used. For instance, when the DC talks about subluxation complex, for a medical doctor, subluxation means that the bones slip out of the joint, but that’s not what it means to chiropractors.
I’ve seen a lot of electronic records where DCs use templates and templates are not designed for pediatric patients. Just like if I get a medical record from a medical doctor where it’s illegible or poorly documented, I have mistrust for that practitioner, so documentation is important and explaining some of the jargon of chiropractic to the MD will go a long way.
Jay Greenstein: Anything you’d like to conclude with?
Dr. Lazoritz: The field of chiropractic is a little confusing to me. There seem to be different groups of chiropractors. Some are evidence-based. The fear of a lot of medical doctors is that their patients may go to a chiropractor who is not in the mainstream of evidence-based chiropractic.
Jay Greenstein: Over the past 20 years, which is how long I have been a DC, the evidence-based approach has grown tremendously.
Dr. Lazoritz: I view chiropractic as being part of the wider healthcare team. The company I work for, Arbor Health Plan, and our parent company Ameri- Health Caritas, believes in the team approach to management of patients. That’s how I feel about chiropractic, part of the team that cares for patients and helps them stay well.
Dr. Greenstein is the CEO of the Sport and Spine Companies– Sport and Spine Rehab, Sport and Spine Athletics, Sport and Spine Rehab Clinical Research Foundation and Kaizenovation® Consulting, which coaches businesses on Six Sigma, human capital management and the Entrepreneurial Operating System.® Dr. Greenstein sits on multiple chiropractic boards, as well as community and business advisory boards in health care, banking and information technology. He can be reached at drjay@]kaizenconsult.com.
Stephen Lazoritz, M.D., C.P.E., is the network medical director for Arbor Health Plan, responsible for all of Arbor’s medical programs, including medical management initiatives, utilization management and meeting AmeriHealth Caritas Family of Companies’ annual Medicaid health care quality goals. Dr. Lazoritz is an accomplished pediatrician, health care executive, author, speaker and advocate for the health and welfare of children. He is the co-author of four books on child abuse, children’s rights and shaken infant syndrome.