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Dynamic Chiropractic – February 12, 2005, Vol. 23, Issue 04

Research, Theory, Practice and a Bunch of Other Complex Stuff

By Robert Mootz, DC

The new year is upon us, and it's always a good time to take stock of where we've been, where we are, and where we want to go. I continue to be gratified with chiropractic's phenomenal progress in recent years, yet few could argue that we've achieved all we need to.

If chiropractic as a profession is to ever become a default, first-resort resource in health care overall (as opposed to a high priority within our own little circle of supporters), we still have a lot of professional maturation to go through, even before we try to change the world. In no particular order, I offer my two cents on the major issues I believe chiropractors must grapple with head-on.

We Are What We Write

It's boring. It's a hassle. It's thankless. But it's the center of your professional identity. It's your documentation. Your chart notes, your reports, your correspondence, even your advertising. If it's cheesy, incomplete, full of shortcuts, and has inaccuracies ... well, right or wrong, the world perceives the same of you, regardless of how good of a doctor you are. Documentation is a bugaboo of mine. I've lived it from all sides now: 13 years in private and group practice, in the classroom, teaching clinics, medical-legal work, and recently, within an insurer and regulatory policy position. It's unanimous from all angles that documentation is critical. I'm very sad to say, however, from my recent years of viewing documentation of many disciplines, the proportion of chiropractors who do a poor job is so high that it stands out to everyone. We must do better in training, in continuing education, and in our disciplinary boards. Even though it's an annoying hassle, really, we have to.

Embrace Evidence-Based Practice

No, that doesn't mean researchers tell us how to practice, or that payers who inappropriately adopt somebody's "evidence-based" this or that get to tell you what to do. What it means is that in addition to making care decisions based on what you learned to do, what you and your colleagues talk about doing and what you've become comfortable at doing; you stay current with what research has shown and start factoring that into how you make decisions and how you modify what you do. If something seems to be more promising than the status quo, get up to speed on it or ensure that your patient gets the chance to interact with someone who is. It's all about staying current and improving what you do. We're about the same as everybody else in this arena. All doctors tend to become "old dogs" and we all understand that "new tricks," especially as they relate to our own expert reasoning, will meet with some resistance.

Embrace High Ethical Standards - Reduced to Its Simplest, It's the Golden Rule

The patient's interest must always come first in everything we do: balancing enough care with enabling dependence on treatment; balancing incentives (e.g., financial) for doing more against doing the least amount possible to get the job done; and assuring proper professional boundaries are maintained. It's all a bit harder for us, I think. Our patients really like what we do. Our methods are extremely safe, quite effective and typically of low cost. Not to mention, by the very nature of our patient encounters, we are frequently closer physically and often emotionally with our patients than many providers. We can never lose sight of the responsibility we have.

Improve Our Cost - Competitiveness for Similar Documentable Outcomes

Compared to unnecessary surgery, harmful bed rest and gnarly steroidal medications, pretty much any old chiropractic approach looked good. Today, early activation, lower side-effect nonsteroidals and more emphasis on appropriate patient selection for surgery are common with the "competition." In the meantime, much of the emphasis in chiropractic in recent decades has centered on practice management to enhance income, rather than finding ways to always do it better, faster and cheaper. There is more competition today in the mainstream, and DOs and PTs are embracing conservative, functional restoration and self-care approaches that hold up well against many of our approaches. Costs and durations of care, along with comparative outcome studies of different techniques and interventions, will be more routinely considered by policy-makers and frankly, should be more routinely considered by us in improving the efficiency of our own care. To date, it seems to be that only the managed care networks study and report on this sort of stuff, and unfortunately, their strategies often focus primarily on cost-containment or utilization issues, rather than on quality improvement. It becomes adversarial. Outcome, value, practice overhead costs, and various indirect costs all need consideration in cost-effectiveness analyses. If attention to quality improvement and bang-for-the buck isn't on our radar screens right now, believe me, it will be any minute.

Live With Differences Between Indemnity-Financed Condition-Care and Elective Holistic Care

The tension between condition care, holistic wellness and prevention care is not conceptual; it is financial. No one argues that patient-preference, prevention, and lifestyle are important considerations for health care. However, existing models to finance health care are developed around indemnifying rare, expensive and/or catastrophic events. When everyone needs the treatment, using an insurance model to fund it costs more than just having everyone buy it for themselves. New kinds of policies testing discretionary benefits (like medical savings accounts), capped prevention services (dental or prenatal care), and various deductible and copay incentives are coming to market, and others may evolve. But one trend is certain: Accountability and justification to get substantial and prolonged insurance reimbursement will continue and most likely will increase.

Congruence of Our Theoretical Models With Social and Scientific Norms

Look, my scientific training before chiropractic school involved university courses and research in metaphysics and parapsychology. I know there's a lot out there that we can't see, feel, touch, or measure. And I have a pretty deep spiritual view of the nature of life and all things in the universe. Not only that, but we have hardly begun to scientifically gain a glimpse into the worlds of molecular biology, genetics, bio-energy, and mind-body relationships. But none of that provides an iota of an excuse to engage in the psychobabble, deductive double-speak, pseudo-science, or as my long-time-pal Joe Keating likes to say, "gobbledygook," that is all too frequently passed off as legitimate chiropractic theory. There is nothing wrong, in great deference and humility before the great unknown, with explicit acknowledgement of the body's self-healing capacity and the importance of prioritizing minimalism in care, or advocacy of our perceived importance regarding structure-function relationships. However, there is a huge amount wrong with arrogantly proclaiming we have the market cornered on harnessing all things vitalistic, or that we have some kind of more enlightened knowledge than mere mortals or "medipractors," and therefore do not need to embrace the rigors of contemporary clinical practice, accountability, or research protocols.

Become a Constructive Community Resource (as Opposed to a Whiny Special Interest)

Both at the individual level and the organized professional level, we will make more friends, get more seats at the table, and have a greater opportunity to influence the way things go when we 1) understand and can articulate larger community and social interests regarding public health; 2) recognize how our needs and interests impact others' needs and interests; and 3) bring constructive engagement and problem-solving strategies to the policy-makers and decision-makers of the world. Whom do you prefer to work with? Someone who comes with an understanding of what you're up against and arrives with their sleeves rolled up, asking how they can help? Or someone who comes in attacking you for your history of discriminating against them, along with tales of how you put their grandfather in jail, and railing on you that all the folks you know and trust and have worked with your whole life are wrong and need to be tossed aside?

It's tempting to think that we really need to focus our energy on changing the world (e.g., how the surgeons practice, how the insurance industry makes business decisions, how the politicians and policy-makers regulate) before, instead of, or while simultaneously addressing our own foibles. Of course, injustice or bad policy decisions must be exposed to the daylight. But I would argue that being the best you can be actually establishes the prerequisite credibility to get the seats at the table to expand our influence, and thus, our ability to actually have a chance at changing the world. Just because you are loud and throw rocks from the outside, doesn't mean you'll be listened to or that your point of view will be embraced by the mainstream. We've got people's attention. We need to deliver. And while we've come a long way, there's so much more to do. Oh, and by the way, the job of getting better is never really done.

Robert Mootz, DC
Associate Medical Director for Chiropractic,
State of Washington Department of Labor and Industries
Olympia, Washington

Click here for previous articles by Robert Mootz, DC.

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