Issue 2 - January 2003

On common ground: Should DCs and pain-management MDs stand together?
By Paul Sandhu, MD

If you think the medical specialty of pain medicine and management (PM) is an unlikely ally to chiropractic, you may want to think again. Among the many medical disciplines chiropractors typically encounter, PM specialists often have a lot in common with DCs with regard to training, philosophies of care and treatment protocols.

If the thought of medical pain services conjures up visions of symptom-focused procedures, perpetual medications and patients in a stupor, you may not be informed about current trends in pain management or what the profession shares with your own. PM physicians share a common ground with DCs.

For example:

•Aligned philosophies. The pain-specialty MD most likely has the training and treatment philosophy most aligned with chiropractic. This training allows them to offer DCs co-management services that blend seamlessly with their treatment plans when additional protocols are required.

•Shared orientation. Since many PM professionals are physiatrists, they share the biomechanical and neurological orientation of ortho/neuro specialists as well as the nonsurgical and conservative intent of chiropractors.

Although some pain practitioners are trained in anesthesiology and occasionally in other medical disciplines, they usually share the chiropractor’s interest in neuroanatomy, functional restoration and the progress of the patient in a restorative sense.

•Mutual goals. The primary goal of PM specialists – and DCs – is to help patients improve or recover. None of us gets satisfaction from assigning a patient to long-term drug therapy or other continuing medical interventions.

•Last resort caregiver. Both PMs and DCs share the regular feature of having difficult and complex cases arrive daily at our doorsteps that have not succeeded elsewhere. For these reasons, PM specialists have more in common with DCs and can provide a synergy of care that members of mainstream medicine frequently cannot offer.

“I have found that physiatrists and anesthesiologists are far more cognizant of what I do,” says Steve Collins, DC, CCSP, MUAC, Diplomate of the American Board of Disability Analysts and Fellow of the Academy of Forensic and Industrial Chiropractic Consultants. “My philosophy is to take patients as far toward improvement as I can under my own care. When I hit a roadblock, I want to work with professionals who have common goals and a similar desire to avoid surgery and invasive procedures.”

Should MDs and DCs “marry?”

From the MD’s perspective, the benefits of a “marriage” between MDs and DCs include:

•A focus on improvement. We would prefer to coordinate methods and protocols that help patients improve in order to avoid more extreme interventions and continuing care. Pain-practice MDs are often more open-minded to adjunctive, alternative and non-allopathic therapies. Whatever helps the patient recover should be the highest goal of any health care provider and due to the complexity and difficulty of many of our cases, PM specialists are at the forefront of integrated care.

•A natural step. DCs provide highly qualified manipulative and physiotherapy methods, including manipulation under anesthesia, so their services are frequently preferred over those of physical therapists. Chiropractic is a natural inclusion for PM patients with musculoskeletal dysfunction or physiological pain.

•Cost-effective care for patients. For most MDs considering chiropractic referrals, the cost of prescription drugs often equates with the cost of chiropractic care, making it a far more beneficial choice for patients.

From the DC’s perspective the benefits include:

•Easy access for consults. Most PMs are easily accessible for consultations on medical issues. DCs also know that their referrals are being made to a chiro-friendly and non-competitive medical professional. “I have found that patients who receive full disclosure of their treatment options and appropriate medical co-management when required have a much higher level of retention,” says Dr. Collins.

•Co-management to buy time. The PM specialist can provide short- or long-term co-management for patients with acute or continuing pain that is interfering with restorative chiropractic care. According to Dr. Collins, “Pain-control services can buy important time for patients who are avoidant of the activity or treatment they need to progress.”

•Electrodiagnostic testing or consultation. PM specialists can offer these services when they are required and many perform new minimally invasive procedures that can help patients avoid more extensive surgeries.

•Professional liability ‘insurance.’ Another matter to consider is that of professional liability. Some of the most serious neurological conditions patients can develop in association with orthopedic injuries are also some of the most unrecognized or misdiagnosed by the majority of health care professionals. Several neuropathic pain syndromes such as reflex sympathetic dystrophy (RSD) or complex regional pain syndrome often go undiagnosed until their window of treatment has passed.

Chiropractors need to know that when neuropathic pain is unresponsive to their care, expedient referral to a pain specialist can reduce or eliminate the sequelae and litigation often associated with these conditions.

“DCs need to educate themselves about these conditions and realize that when patients need medical intervention, they need it now,” says

Dr. Collins. “Adjustments will often correct sub-clinical RSDs, but when cases don’t resolve, get them out quickly.” Once again, because of their specialization, pain practice MDs can provide the most efficacious treatment, typically nerve blocks, during the time period before these conditions become patterned in the central nervous system as chronic pain.

While these conditions are relatively uncommon, timely consult and referral to the appropriate professional can be critical for the affected patient. This is definitely not the time to trust the usual process of sending your patient back to his or her primary physician for advice. The time lost as the patient waits for more referrals, diagnosis and eventual care can exceed the time period for successful intervention.

•Industrial case co-management. If your practice includes workers’ compensation cases, you may want to consider the benefits of well planned co-management protocols for patients. For example, in California beginning in January 2003, all new workers’ compensation injuries are subject to a change in the “presumption of correctness” standard. This change will eliminate the primary physician’s opinion as dominant over a QME/AME report, unless the patient had predesignated the primary provider.

This decision means that cases with well-documented and congruent reports from various specialties are more likely to avoid arbitration and litigation than less substantiated cases. “Multiple reports and agreements about medical necessity certainly help make cases more ‘bulletproof’,” says Dr. Collins.

Douglas Bell, DC, CCSP, QME, instructor for the Insurance Education Association, and supervisor of industrial and personal injury cases for Life Chiropractic College West, says, “In my experience, members of the workers’ compensation system like to see the same opinions about diagnosis, prognosis, and care from multiple specialists. And they are particularly interested in seeing patients improve under care. They commonly want multiple corroborating opinions before a final determination of permanent and stationary is made. For that reason, I believe the workers’ compensation system is at the forefront of professional co-management trends.”

•Validity of claims. Working with a medical specialist with well aligned goals and methods can help reinforce cases, the validity of claims or the medical necessity of care. This can be true in other non-industrial settings as well, such as personal injury cases or standard medical insurance claims. Dual or multi-professional co-management and concurring reports make denials of claims more difficult. And since patient improvement, active care and functional restoration are key issues in third party reimbursements, choosing the right medical professionals as resources for co-managed cases is paramount.

“No matter what your practice philosophy, an association with a pain management specialist can be beneficial,” says Patricia Hospy, DC, president of The Parian Company, a communication and marketing consulting firm.

“Whether you envision an occasional consultation with a medical professional who understands and endorses chiropractic, or your practice includes co-management teams and on-site pain management services, all DCs have something to gain through these associations. And the potential practice development opportunities for cross-referrals, improved retention and patient satisfaction are considerable,” she says.

And because DCs differ, as do MDs, finding the right association is important. Although co-management may be the future of health care, be sure you aren’t pursuing the right relationship with the wrong professional. The right association can be a winning combination for everyone involved.

Paul Sandhu, MD, is a physiatrist and pain management specialist with offices in Oakland and Walnut Creek, California.