Chiropractic at the Boston Marathon: An Integral Part of the Team
Dear Editor:
In regards to Dr. Mui's experience at the Boston Marathon, I applaud him for all the help he gave to the runners during such a horrific event. [Read "A Day to Forget, a Day to Remember" in the July 15 issue.] I have been the director of chiropractic at the marathon since 1985, and actually started the involvement of chiropractic with the Boston Athletic Club and marathon.
In the Dr. Mui interview, he noted that the chiropractors were in the lower level of the John Hancock Building, which is where the chiropractic section of the marathon has been for close to 10 years now. We have been in other locations as well since 1985, but chiropractors have finally retained their own identity at the race and have a separate area devoted just to us.
We do more than "rehab"; we provide chiropractic care along with rehab. The mammoth effect of chiropractic adjustments on the nervous system for these athletes, in conjunction with the massage team we work with, has brought back runners to us year after year. Most runners comment on how impressive our team is and how grateful they are that we provide this service.
In the interview, Dr. Mui described the medical tent as medical trauma care and not chiropractic. Granted, the situation in the tent changed after the bombs exploded to a MASH-like situation, which in no way would involve chiropractic. The tent is basically a mobile trauma center and as such is staffed with plenty of MDs, podiatrists, IV nurses, PTs and athletic trainers, which is why we have a separate location in the John Hancock Building. These doctors and support staff have been trained in trauma and even though the bombing was a stressful situation, they are and were better equipped psychologically to handle such an event. The Boston Athletic Association has the most well-staffed medical care for athletes in the world.
The point of this letter is to set the record straight on chiropractic involvement at the Boston Marathon and to emphasize the concept of being a distinct healing art that is not medical care, but can work with the medical profession as an integral part. Doctors of chiropractic should be proud to have such a unique gift of healing that no other profession can offer. Having a separate department of chiropractic at events such as the Boston Marathon takes a lot of work to develop, and should continue to foster integration with other healing arts and augment the total care of the patient.
Bruce Indek, DC
Director of Chiropractic
Boston Marathon
A Few Notes About SOAP Notes
Dear Editor:
I would like to comment on "SOAP, A Chiropractic Perspective" by Dr. Ron Short and a follow-up article, "SOAP Notes: It's Time for a Cleaning" by Dr. Jim Edwards. When I read Dr. Short`s article, I felt it was useful and for the most part accurate. Hopefully it reached the medical claims review audience, but not likely. I specifically agree with him that when a patient initially presents for the episodic care of a condition or conditions, the chiropractic physician should obtain a history, perform an appropriate evaluation, develop diagnostic impressions and make clinical decisions based on the information gathered. I also agree with Dr. Short that primarily the DC is the one responsible for delivering the majority of the care plan.
What I am not clear about is Dr. Edwards' assertion that somehow the ACA, in its Clinical Documentation Manual, 3rd Edition, suggests it is necessary to perform and document evaluation / management work on each and every follow-up / subsequent patient visit. To paraphrase Documentation Recommendation 12, routine follow-up visits should include: significant changes or lack thereof in the patient`s subjective complaints and objective findings; significant changes in assessment or clinical impression; and changes to the care plan where applicable.
The manual further states that the purpose of documenting patient status is to assist in establishing the clinical necessity of ongoing care and patient status should be documented briefly each visit and more extensively when indicated (emphasis added). These documentation recommendations were developed through a consensus panel and approved by the ACA Board of Governors.
Dr. Edwards is correct when he states that we practice as physicians. But as he suggests, we don't cease to be physicians and become technicians during the treatment phase of care. I really don't think we should publicize that somehow we have conflicting roles when it comes to providing physician-level services.
We are required to make clinical decisions on each and every visit. Granted, some encounters are simple and perhaps routine; others more comprehensive. The level of work necessary is left to the clinician. The bottom line is the health record should reflect clinical findings to support the management of the patient.
Dr. Short makes a valid point in that claims reviewers should not be allowed to make judgment on patient care based on incomplete records. The ACA, through its Medicare and Insurance Relations committees, recommends providing the entire patient file when being reviewed or audited.
The American Chiropractic Association has and will continue to support the highest physician-level, patient-centered care for our patients. And we continue to support reasonable record-keeping tenets.
Anthony Hamm, DC
Vice President, ACA
Defending Scope of Practice in California
Dear Editor:
This letter is in response to a letter to the editor from John Ventura, DC, regarding the article, "Wild West: DCs Take on PTs," in the April 15, 2013 issue of your publication. Dr. Ventura took critical issue with the California Chiropractic Association’s (CCA) manipulation / adjustment bill, SB 381. After reading his comments, I can say emphatically that he missed the point of this bill en-tirely.
The purpose of this legislation is to address the performance of joint manipulation / spinal adjustments by providers who do not currently have the ability to perform this procedure as a part of their scope of practice. Medical doctors have an open scope of practice and can perform manipulative procedures regardless of whether they are trained or not. Like it or not, that is reality. Osteopaths have manipulation as a part of their scope as well.
The CCA is not trying to limit any provider’s current scope. However, physical therapists, naturopaths, massage therapists, ath-letic trainers, etc., do not have manipulation / adjustments within their scope of practice in California at this time. Any provider group that wants to increase its scope of practice needs to run legislation demonstrating the education and training they receive that supports the increase in scope.
In California, an Attorney General opinion clearly states: "a physical therapist may not directly manipulate or adjust the spine or any other bony structure," yet PTs continue to blatantly claim that they are doing it. So, regardless of any training or evidence-based research, in California it is against the law, but is currently not being enforced by the state board that regulates PT practice.
There is no hypocrisy with the CCA, and Dr. Ventura’s Texas Medical Association analogy is ridiculous, as that was an attack on the ability of doctors of chiropractic in that state to diagnose, something that is already in their current scope.
Doctors of chiropractic in neighboring Oregon can prescribe medications and perform minor surgery. That does not make those services a part of our scope of practice here in California. If the doctors in California decide to expand their scope, they too will have to provide evidence of training and pass legislation. SB 381 is about scope of practice; no more, no less.
Kenneth Winer, DC, Governmental Affairs Dept. Chair
California Chiropractic Association
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
