Part of the Evidence in Action series by Palmer College of Chiropractic
By Heather Mai-Roecker, DC, ARNP, and Christopher B. Roecker, DC, MS
The public primarily perceives the chiropractic profession as a healthcare discipline involved with the management of spine-related pain and disability.1 Unfortunately, the current state of spine care in the United States is dominated by specialists, who tend to function in isolation, with minimal communication between providers.2,3
While this may have been the way it has been in the past, we feel it doesn’t have to–and shouldn’t–stay this way. While few medical providers and doctors of chiropractic (DCs) currently work in the same facility, a growing number of DCs are working within multidisciplinary settings or working collaboratively with other providers.4,5 Regardless of the practice setting, we believe all DCs have opportunities to improve patient care by adopting a more interprofessional approach to care.
One way to improve patient care is to further develop interprofessional communication between the various providers involved with spine care. The current state of interprofessional communication between traditional medical providers and DCs is suboptimal.5 Here are a few related facts:5-7
- Most medical providers rarely refer patients for chiropractic care and about 1/3 of these providers never refer patients for chiropractic care.
- Most (87%) medical referrals to DCs are informal and require the patient to initiate the referral process.
- After referring a patient to a DC, medical providers rarely receive any follow-up information, such as a status report.
- When receiving a referral from a DC, medical providers commonly report not receiving any associated clinical information, such as the reason for the referral.
Improved collaboration between DCs and other health care providers stands to enhance the quality of care provided to our patients. We believe that poor interprofessional communication acts as a barrier to patient-centered care. The remainder of this blog will focus on ways to improve professional communication.
Written referrals and progress notes are a common method of interprofessional communication. Many providers judge the quality of a clinician by their written communication, and small improvement in writing style may dramatically impact how written communications are perceived. A 2012 article published in The Chiropractic Report, titled “The Art of Writing Letters and Reports,” does a great job of outlining effective written interprofessional communication.8 This article emphasizes that written letters are customary when: 1) you refer a patient, 2) a patient is referred to you, and 3) when a referred patient completes their course of care. If you are referring a patient to a specialist, it is appropriate to copy the referral letter to their primary care provider. Additionally, DCs should ensure that the patient is aware of, and approves of, your intention to communicate with their medical providers.
Format and Length
Key principles in written communication revolve around being professional.8 The letter should have a professional appearance and be written on letterhead. We highly recommend writing in a manner that is clear and concise. Summarizing your content is critical and allows busy providers to quickly understand the reason for your communication. We strongly recommend limiting your writing to no more than one page in length9 and, if absolutely necessary, including additional information as an attachment to the summary letter. Contrary to popular belief, a short well written letter is more impressive than one that is lengthy and highly detailed.8 It is also important to ensure that your writing is well organized, and clearly communicates the goals of care and the treatment plan.8
Because each health profession has its own unique terminology that is relatively unknown to other health professions, keeping your writing free from jargon is important. Communicating with other providers should involve universally understood terminology that clearly describes the details of the patient’s care and avoids terms that may be poorly understood or misunderstood. It has been noted that medical providers “are not interested in, nor do they understand, subluxation listings or motion palpation findings.”8 We acknowledge that excluding the term “subluxation” is a sensitive topic. Due to the fact that subluxation has different meanings for different health professions,10 we feel it is more productive to describe this concept in a manner that is more universally understood, such as “joint dysfunction,” “fixation,” or “restriction.”5,8
Spare the Details
One main purpose of interprofessional communication is to express big-picture messages instead of going into exquisite details. Generally speaking, other providers are unlikely to desire high-level detail, such as the subtle findings related to individual spinal segments, which DCs have a tendency to include. A summary of history, disability, significant exam findings, and primary diagnosis is most likely to be useful to other providers.8 Table 1 provides recommendations for elements to include or avoid when engaging in interprofessional communication.
Recommendations for Interprofessional Communication
Recommendations to Consider Including5,8,9
- Professional language
- Office letterhead
- Clearly stating the reason for the referral or communication
- A clinical summary that is 1-page or less in length
- If lengthy clinical information must be included, attach as a separate document
- Summary of goals, diagnosis, prognosis, treatment plan, and current progress
- Your contact information
Recommendations to Consider Avoiding
- Chiropractic jargon
- Any abbreviations that are not critical to understanding the clinical scenario
- Listing specific segments that were treated (e.g. C2, T8, L4)
- Chiropractic technique listings or other spinographic listings (e.g. PRS, BR)
- Minor asymmetries, such as subtle leg-length inequalities
- Thermography findings (e.g. Tytron reports)
- Educational information about the chiropractic profession or specific techniques
Today’s health care environment emphasizes collaborative patient-centered care, which involves interprofessional communication to optimize patient outcomes.11 When healthcare providers do not communicate, the patient is caught in the middle and their quality of care may suffer.9 If we stay mindful of how we communicate, we stand to enhance the quality and coordination of care while increasing the level of understanding between medical providers and chiropractors.
- Weeks WB, Goertz CM, Meeker WC, Marchiori DM. Public Perceptions of Doctors of Chiropractic: Results of a National Survey and Examination of Variation According to Respondents’ Likelihood to Use Chiropractic, Experience With Chiropractic, and Chiropractic Supply in Local Health Care Markets. J Manipulative Physiol Ther. 2015 Oct;38(8):533–44.
- Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine J. 2008 Jan;8(1):1–7.
- Murphy DR, Murphy DR. Clinical Reasoning in Spine Pain. Volume I: Primary Management of Low Back Disorders Using the CRISP Protocols. 2013. 328 p. 3
- Dunn AS, Passmore SR. Consultation request patterns, patient characteristics, and utilization of services within a Veterans Affairs medical center chiropractic clinic. Mil Med. 2008 Jun;173(6):599–603.
- Allareddy V, Greene BR, Smith M, Haas M, Liao J. Facilitators and barriers to improving interprofessional referral relationships between primary care physicians and chiropractors. J Ambul Care Manage. 2007 Oct;30(4):347–54.
- Greene BR, Smith M, Allareddy V, Haas M. Referral patterns and attitudes of primary care physicians towards chiropractors. BMC Complement Altern Med. 2006 Mar 1;6:5.
- Greene BR, Smith M, Haas M, Allareddy V. How Often Are Physicians and Chiropractors Provided With Patient Information When Accepting Referrals? J Ambul Care Manage. 2007;30(4):344–6.
- Chapman-Smith D. The Art of Writing Letters and Reports. The Chiropractic Report. 2012 Jan;26(1).
- Salsbury SA, Goertz CM, Vining RD, Hondras MA, Andresen AA, Long CR, et al. Interdisciplinary Practice Models for Older Adults with Back Pain: A Qualitative Evaluation. Gerontologist. 2017 Jan 11.
- Johnson C. Use of the term subluxation in publications during the formative years of the chiropractic profession. J Chiropr Humanit. 2011 Dec;18(1):1–9.
- Mior S, Barnsley J, Boon H, Ashbury FD, Haig R. Designing a framework for the delivery of collaborative musculoskeletal care involving chiropractors and physicians in community-based primary care. J Interprof Care. 2010 Nov;24(6):678–89.