ONLY 3.6 PERCENT of doctors of chiropractic (DCs) hold staff privileges at a hospital, according to the National Board of Chiropractic Examiners’ 2015 Practice Analysis of Chiropractic. Gaining hospital privileges may present many hurdles – either temporary or long-lasting – but in the long run, DCs who accomplish that goal will see the many benefits that working in a hospital can offer their patients, the profession and themselves.
Scope of Practice
Before making a commitment to a hospital, you have to ask certain questions, according to Leo Bronston, DC, the American Chiropractic Association’s (ACA) Wisconsin state delegate and a past chairman of ACA’s former Integrative Practice Committee. “Will they [hospital leaders] change my treatment plan?” he asks. “Who is my market? What exactly do the hospital privileges look like in the 3.6 percent of DCs working in hospitals? You have to know what services you can deliver,” he says.
A DC’s scope of practice may be limited in the hospital workplace, but this is not always permanent. In 2000, Matthew Kowalski, DC, was invited to become a member of Osher Clinical Center for Integrative Medicine at Brigham and Women’s Hospital, a major teaching hospital of Harvard Medical School, where he is employed now. The first draft of the chiropractic hospital privileges prohibited the administration of cervical spine manipulation, which made Dr. Kowalski reluctant to proceed. But through the education of key hospital leadership and with the strong support of the clinic medical director, the scope of practice restriction successfully was eliminated.
Another hurdle the chiropractic profession faces is the prohibition of ordering diagnostic imaging studies. This applies to any profession not allowed to do so under Medicare. Dr. Kowalski remains optimistic that this will change soon as he has the support of key policymakers to do so.
DCs may need to challenge hospital bylaws and educate hospital administration in order to be able to perform their statutory scope of practice.
Bylaws and Integration
Dr. Kowalski notes that the first hospital he worked for in 1994 was very open to the idea of a chiropractic physician working in the hospital. He asked for an application from the medical director of the hospital, completed it and eventually had an interview with the same individual. He explains that seeing no reason not to hire him, the hiring committee worked to change the bylaws at the hospital, which at the time had a provision that actually restricted clinicians from referring to, accepting a referral from, or co-managing patients with a chiropractic physician.
The medical director of the hospital, James Liljestrand, MD, went on to assist other medical directors in Massachusetts and other states about how to incorporate chiropractic into their health care system.
“The key is to understand that these positions do not just appear on job sites like every other medical profession,” says Jesse Cooper, a DC who works for UNC Regional Physicians Physical Medicine & Rehabilitation, a subsidiary of High Point Regional UNC Health Care. “They must be created. This takes time.”
Dr. Cooper recommends relationship building as a first step in the process of acquiring hospital privileges. He completed a three-month preceptorship at the hospital where he now works while he was still in chiropractic college. This gave him an opportunity to learn the key players of the hospital, which consequently led him to become sponsored by a hospital physician, required for practitioners of a specialty not currently integrated into the hospital.
The sponsoring physician must convince a medical staffing committee that the new position is valuable to the organization, he explains. The committee’s majority vote is required to grant hospital privileges to the individual.
In addition, Dr. Cooper wrote a wellresearched proposal and business plan that he presented to his sponsoring physician, as well as to the senior leadership of the hospital. “My proposal detailed the need for conservative, evidence-based musculoskeletal care, the process in which I would deliver it, the research supporting these processes, and most importantly, how my addition would impact the hospital’s bottom line,” he says. “Have your plan of action memorized front and back. Know your script.”
Dr. Kowalski believes that one’s trustworthiness and amicability play a pivotal role in getting the job. “Building a trusting relationship will make this opportunity flourish,” he says. “They [DCs] must proceed softly and relate to other medical practitioners, get to know the hierarchy and respect the hierarchy.” Forge such relationships early on, before even entering the professional world, and hone your image and behavior to the highest level of professionalism, he advises.
Finding Your Niche
Upon the granting of hospital privileges, chiropractic physicians must consider which department is most appropriate to accommodate their skills, if that decision has yet to be made. DCs should aim to work in the emergency department, for example, and become the referring doctor for patients with uncomplicated low-back pain, suggests Dr. Bronston.
Chiropractic physicians are also well-suited for physiatry, which usually coincides with physical medicine and rehabilitation; pain management; internal medicine; and family care.
In a research study, Branson found that in a Minnesota private health care system, individuals referred themselves to chiropractors and that DCs also received referrals primarily from primary care physicians, sports medicine doctors and orthopedic medicine doctors, with occupational medicine doctors trailing behind.1 These are the same departments where DCs should strive to become integrated.
“Referrals are coming from primary care physicians, the medical director of the Center for Integrative Medicine, pain management and surgery departments,” says Dr. Kowalski, of Brigham and Women’s Hospital.
He has also noticed an uptick in patients who are being directly referred into the integrative care sector of the hospital, unlike in the past when the majority of patients had already used a gamut of medical services (e.g., rehabilitation services and surgery) prior to referral.
Research Is a Must
As part of the hospital and while working alongside MDs who may be either accepting of or skeptical of chiropractic, DCs should stay up to date on the latest research supporting chiropractic services to bolster their standing as experts on musculoskeletal disorders.
Specifically, DCs should be aware of the tripleaim initiatives practiced in U.S. hospitals: patient satisfaction, clinical outcome and cost savings — know the chiropractic research that supports each of these, both before getting the job in a hospital and during a career as a hospital-based employee. [Read more about incorporating research into your practice in “Add Evidence Into Your Treatment Plan,” November 2015 ACA News, Page 18.]
In a study regarding the facilitators for the acceptance and growth of chiropractic in the hospital, Branson wrote, “A firm knowledge of the scientific basis of safety and effectiveness of treatment within the scope of chiropractic care was essential. This knowledge base was critical during initial discussions at the numerous hospital committee meetings and physician presentations. This firm resolution by the chiropractor, hospital administration and clinical staff to use evidence-based evaluation and treatment methods was a key component to the acceptance and growth of the chiropractic service line within the hospital system.”(1)
DCs can increase their exposure to a variety of health issues in the hospital, making them better and more informed practitioners. If a patient is referred to a DC for a musculoskeletal disorder, the DC may have an opportunity to pick up on comorbidities, leading to a referring opportunity and the initial interaction necessary for creating a relationship with a new medical professional.
Dr. Cooper reminisces on one of the most challenging experiences of his life – working as a student under a preceptor at High Point Regional UNC Health Care – where he took histories and performed physical examinations on stroke patients, amputees and patients with knee and hip replacements or neurological and vascular disorders. “I saw pathology that chiropractic students only read about,” he says.
In addition to exposure, collaborating enables DCs to educate the medical profession about their knowledge of musculoskeletal disorders and to demonstrate the effectiveness of their treatment plans for such disorders. Unfortunately, some medical doctors don’t entirely understand chiropractic and how it can benefit patients. “They are ridiculously busy, and most often aren’t going to seek the answer,” says Dr. Kowalski. “The answers have to be brought to them. Inform the medical profession of what you can do.” One way to do so is to become competent in clinical documentation via a shared electronic health record system – a commonality in hospitals. This facilitates the communication of a patient’s treatment plan with an MD.
It is most important to convince a medical professional of your competence in certain areas for the sake of the patient. “Too often I hear DCs seeking hospital privileges as a mechanism to receive more referrals or a way to bolster referrals into their private practice,” says Dr. Kowalski. “Work on relationships that will help our patients. Working in a hospital isn’t about receiving referrals. It’s about helping patients in an integrated system. The point is to integrate into a health care system to help patients at a higher level.”
Building strong and trustworthy relationships and proving chiropractic’s high-quality, effective care and high patient satisfaction rate with the use of the latest chiropractic research are just a couple of ways to create cultural authority in the hospital. “Cultural authority is a byproduct of chiropractic’s professional development and universal acceptance of its legitimacy and competency,” says Dr. Cooper. “There is no better avenue to achieve cultural authority in health care than through its primary institution – the hospital.”
“Nobody does conservative evidence-based functional restoration of the musculoskeletal system like we do,” says Dr. Cooper. “Nobody understands movement like we do, particularly spinal biomechanics. Do not be intimidated, but be humble – find a balance. Hospital integration is ultimately a very rewarding experience.”
- Branson, RA. Hospital-based Chiropractic Integration Within a Large Private Hospital System in Minnesota: A 10-Year Example. JMPT. 2009.32.9.
See an example of hospital bylaws that now fully incorporate chiropractic into their hospital staff privileges here: http://bit.ly/1NRemh8.
INTEGRATIVE PRACTICE RESOURCES
• More and more doctors of chiropractic are working in integrative or multidisciplinary settings. Several ACA News articles discuss why and how to work in such an environment. Visit www.acatoday.org/integrativepractice to view the articles.
• American Chiropractic Association (ACA), the ACA’s Rehab Council and the Laser Spine Institute have collaborated to bring DCs an opportunity to learn about treating patients who have undergone minimally invasive surgery via the Post-Surgical Spine Rehabilitation training. The seminar instructs DCs on how to manage complex surgical cases and engage in effective communication with the medical community to convey the role of chiropractic. Learn more at www.acatoday.org/PSSR.
• ACA provides its members with free webinars twice a month. Look for a future webinar on hospital privileges and protocols. Visit www.acatoday.org/webinars.
TO PREPARE FOR HOSPITAL PRIVILEGES (as summarized by Dr. Matthew Kowalski):
1) Work on your professionalism and further your education in chiropractic. Learn to develop thick skin.
2) Develop interprofessional relationships. Begin as soon as you decide to become a chiropractor. Visit and/or shadow doctors.
3) Seek out a mentor.
4) Know the terrain and climate of the hospital you would like to approach.
5) Request a meeting with the medical director or key contacts (e.g., in the physical medicine and rehab departments).
6) Know what you are seeking (e.g., types of privileges, departments and compensation structure).
7) Be patient, humble, and remember that you represent the profession.
8) Know when to walk away or stand your ground. Don’t compromise your practice.
Amanda Donohue is ACA’s communications coordinator.