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Dynamic Chiropractic – June 4, 2005, Vol. 23, Issue 12

Integrative Medicine in the Hospital Setting: An Interview With Bryce Milam, DC

By Michael Devitt

Like many practicing chiropractors, Bryce Milam had a personal experience with chiropractic that changed his life and led him to enter the profession. After suffering a back injury and failing to get relief from painkillers and other medications, Milam consulted his mother's chiropractor for care.

Within six months, his back pain was relieved - and he had decided to enroll in chiropractic college.

In 1982, Dr. Milam graduated from Western States Chiropractic College. He later went on to receive certification in accident reconstruction from Texas A & M University and the Spine Research Institute of San Diego. Among his achievements, he has been named the "Chiropractor of the Year" from two separate associations in Oregon, and founded the Chiropractic Association of Oregon's individual practice association, one of the first of its kind in the United States.

In 2002, Dr. Milam became the first chiropractor to gain privileges at Woodland Park Hospital in Portland, Oregon, but the facility was forced to close its doors in January 2004 due to financial problems. In July 2004, however, Dr. Milam and a group of medical doctors purchased the hospital out of bankruptcy and renamed it Physicians' Hospital, emphasizing an integrative, patient-centered model of care that incorporates chiropractic with traditional medical care, naturopathy, acupuncture and other forms of healing

Recently, Dynamic Chiropractic spoke with Dr. Milam about Physicians' Hospital, the groundbreaking model of care the hospital will implement, and the role chiropractic will play in the care of patients.

Dynamic Chiropractic (DC): How did you become involved with Woodland Park Hospital?

Bryce Milam (BM): I had a contract with Woodland Park that goes back to 1995. I started the Partners in Health program there [Partners in Health Consulting specializes in integrating complementary care into the traditional hospital environment], and developed that program in an effort to find a way to mainstream chiropractic into a hospital setting. I've worked for the last 14 years of my life to integrate integrative medicine models. I began doing that through Partners in Health, and through the years, I made a lot of friends and got to know a lot of physicians. They saw the benefits of the program, not only to the hospital, but also to the medical staff and the patients. When the opportunity came, I pursued it a couple of different ways.

Approximately five years ago, one of the CEOs attempted to buy the hospital out of bankruptcy with a group of physicians, of which I was one. That didn't work out, because the courts awarded the contract to another group, but when the situation came up again, I was asked by some of the core physicians in the hospital if I'd like to participate and help it become successful, with the help of the chiropractic profession.

DC: What was the role of Partners in Health in acquiring the hospital? What are its beliefs on complementary and alternative medicine, or integrative medicine?

BM: Integrative medicine. The term, I think, is truly "integrative." We were CAM for a while, but that was "complementary and alternative." I think it's a better venue, and a better fit for the patient, when it's an integrative approach in which we're all working together. That's been the model for Partners in Health since I started it in 1995. The premise that we operated under was always that what's in the best interests of the patient is first, followed by what's in the best interest of the hospital, the medical staff, and the chiropractic profession. That was the hierarchy that we used when we evaluated our mission and our patient evaluation.

The way I ran Partners in Health, and continue to run it to this day, is that we have monthly meetings at the hospital. During those meetings, the medical profession will hold an in-service in the hospital, in which one of the doctors will get up and talk about what they're doing. They train each other in spotting particular types of pathologies in the early stages, or assist other physicians in managing certain pathologies that may come across their office. Usually these are specialists who are presenting the information and assisting the primary care doctors, so that when they see these things in their offices, they're better able to handle them.

We adopted that model at Physicians' Hospital. We also have a meeting once a month. We'll have one medical speaker; sometimes it's a primary care physician, or an orthopedic surgeon, or a neurosurgeon. We'll also have a chiropractic speaker. We will present cases, and it's done basically along the same lines as rounds are presented in a hospital. It'll either be a case that we've resolved or that we're having difficulty with. It's an interdisciplinary education process. That's been the form that has worked quite successfully over the years.

I think one of the problems that has existed with chiropractic in hospitals and [with] physicians in general is that we as chiropractors have a pretty good idea about what they do - maybe not all of the mechanics involved in, say, doing a back surgery, but we know what back surgery involves. A lot of the medical colleagues do not really know what we do. Their understanding of chiropractic is limited, maybe archaic, maybe unfounded. So, we have developed this rapport where we're able to come in, present a case in a professional manner, and demonstrate the efficacy of what we do, in terms of pre- and post-MR, pre- and post-X-ray, if that's the case, pre- and post-functional capacity analysis, range of motion, resolution of pain, symptomatology, etc. That's been the philosophy of Partners in Health. All of the professions are working jointly for the best interest of the patient.

DC: Physicians' Hospital is going to be run under something called the Planetree Model. Could you describe that health care model and how it relates to Partners in Health?

BM: The Planetree Model is in some ways very similar to the Partners in Health philosophy and mission. Planetree is a nonprofit group that has about 106 hospitals nationwide. It is a mission-driven organization that is designed around patient-centered care. All of the hospitals that participate have to meet a certain minimal standard with regard to what services they offer patients; for instance, libraries, access to information, access to their own charts, more flexible visiting hours for family members, more flexible dietary options, and integrative care models that include but are not limited to chiropractic, acupuncture, naturopathy, massage, yoga, spiritual healing. Not all of these services are available at any one facility, but all of them are available at some facilities. It depends on the geographic location and the medical staff of the facility, but those services are now being offered to assist patients in their recovery.

DC: What role will chiropractic play in this model at Physicians' Hospital?

BM: Chiropractic is obviously going to be the first integrative medicine component that will be in place at the hospital. We intend to have a center of excellence for the spine at Physicians' Hospital, which will be very heavily chiropractic-dependent. We plan to add naturopathic services, acupuncture services, and massage at the hospital in the short term. I'd say that will take place over the next six to 12 months. We will begin to develop some community-based programs such as yoga, and some exercise components as well, such as nutritional counseling.

DC: Say a patient comes into the hospital with back pain. What's the process that the hospital goes through in seeing and taking care of that patient?

BM: The current model would be that the patient would obviously be triaged in urgent care and stabilized, whatever that might entail. They would be referred to the spine center, and at that point, they would be triaged, evaluated, and probably be seen by a chiropractor initially. It's similar to the Texas Back Institute, but I think we're trying to develop a model with chiropractic as the primary evaluator for musculoskeletal spine problems. We would probably see them pretty quickly.

DC: How many chiropractic physicians are on staff right now at Physicians' Hospital?

BM: I think we've got about 80 physicians on staff right now, and between 11 and 14 chiropractors on staff, who are either credentialed or are in some process of credentialing in. We all had to re-credential, because many of us held privileges at Woodland Park. I was able to get privileges at Woodland Park in 2002. I was the first in Oregon, and we were able to get another eight or 10 on in the Partners in Health group there. We are currently in the process of expanding Partners in Health to be more representative of a much larger segment of the chiropractic community. In the past, it was a much smaller group. The politics of the day did not allow for a larger group, but that has since changed.

DC: You mentioned earlier that the medical doctors' beliefs/understanding of chiropractic might be unfounded or archaic in some cases. Where do you think that comes from?

BM: I think it's probably changing somewhat. I know Oregon Health Science University has Dr. Michael Freeman, a chiropractor, who speaks there. I think we're beginning to penetrate their educational areas. More medical colleges are offering electives in CAM or integrative medicine, so that the primary care doctors and the specialists ultimately are getting more of a handle on what we do. But I don't know that they necessarily have the full scope of our background, such as our education and training, the hours we have in anatomy, physiology, and radiology, and the mechanistic and mechanical approaches to what we do with manipulative management.

I think the perception by the medical profession has always been that chiropractic is a "snap and pop" profession. In fact, osseous diversified manipulation, which I perform a lot of in my office, is one of the tools that we use, but there are a lot of other tools of analysis that we use. Diagnostic analysis, CAT scans, MR, radiology ... our level of sophistication and the use of those diagnostic tools have significantly increased over the years, and our application of our art and science is quite varied.

DC: Do you think you'll see less of these perceptions/beliefs from MDs over time?

BM: I believe that will be the case. I've dedicated a large portion of my life to educating the medical profession as to what it is that we do, and where our role is. I think if you were to interview some of our medical colleagues, one of the things they'll tell you is that from their perspective, chiropractic is - or is being - recognized as the primary care base for the spine. I think it would be good to have their input as well.

DC: What has the reaction been from the medical profession to having chiropractors on staff, at that scale, working so closely together? What's the general feeling between the medical doctors and the chiropractic physicians?

BM: Again, I'm going to advise you to talk to the medical physicians to get their perspective, because they're going to give you the true medical perspective. What someone says to my face and behind my back may be two different things. I'm being totally candid here, but obviously, we would not be there if we were not wanted to be there. I think that the group of physicians who are currently involved in the ownership model at Physicians' sees chiropractic as a very significant component and partner in the long-term success of the facility.

DC: What about the other professions, such as acupuncture and naturopathy?

BM: I don't know that the scope is that broad, but they do recognize that patients want these services. This is patient-centered health care. Again, I'll refer to the Planetree Model. It's patient-centered health care in which the patient has some input. Health care is something that the patient participates in, rather than has happen to them. We want to allow the patient to request services. If the patient wants acupuncture preoperatively, the patient should be allowed to have that.

DC: There's a lot of empowerment for the patient.

BM: Absolutely.

DC: What is your goal in terms of chiropractic's inclusion in this hospital, and the role it will play?

BM: I have several goals. It has been my lifelong goal to have chiropractic integrated into health care more and more. While this may be the first hospital that will be participating at this level, I earnestly hope it's not the last one, or the only one. My goal is to have Western States Chiropractic College also be involved in this project, and to have interns go through rotations and rounds in the hospital, so that they're fully trained. They will understand what health care is being delivered in the hospital, how it's delivered, what it looks like, and they will have the opportunity to see pathologies that historically we're not exposed to, or have very limited exposure to, in our chiropractic patients.

The opportunity to witness and watch surgery take place, I think, is invaluable, because it gives the chiropractor a much better understanding of what a postoperative patient has gone through. If you witness back surgery or neck surgery, you'll have a much better understanding of that patient's health, along with what their challenges are and what their future health needs are going to be. I think it's important for us to have that knowledge and understanding. So, obviously I want it to be a situation that the whole profession improves and has the opportunity to benefit from.

I would like to see the DACBR programs at Western States expanded. Dr. Tyrone Wei is at the hospital now, and he's reading live films for pathology. I'm not sure if he's the only DACBR in the United States who is reading films at an actual hospital; several are reading films at outpatient radiology facilities and freestanding facilities, but I don't know if there are any other DACBRs actually reading films at a hospital. That's a new scenario.

I would like to see chiropractors learn to work in a team setting more. Obviously, we have political issues that preclude us from working together on a unified basis, but hopefully from a clinical model, we can put some of that aside and learn to work in an integrative care model that improves not only patient care, but the ability to deliver care within an integrative system. The ability to pick up the phone and call somebody and ask a question, or arrange a referral on a rapid basis, and to have that one-on-one dialogue, is really very exciting.

I had a low-back pain patient from a car accident last week, who also developed a nephritis. I was able to call, order the tests, and arrange for a specialist within 24 hours. He underwent the testing, had the diagnosis confirmed, and was seen by a urologist within 24 hours. That's good patient care, as opposed to saying, "Well, you need to go see a medical doctor for that," and the patient doesn't know where to go or how to access that care. Managed care is obviously a significant component, and that can be very difficult to navigate, not only for the chiropractor, but especially for the patient. With our model, the chiropractor is able to quickly delineate what that patient needs and facilitate it within that patient's health plan, which will minimize that patient's discomfort substantially, especially over a period of time.

DC: Where do you see this model of care in the next five to 10 years, and what are your hopes for chiropractic and integrative medicine?

BM: Obviously, chiropractic is not by nature a hospital-based type of practice. However, I do think there is a role for chiropractors who want to practice in a hospital, pain center, or spine center. I think that definitely exists, and I think that's a center that should exist to support the chiropractic profession as well, not something that competes with it.

The osteopathic hospitals have manipulative departments within the walls of their hospitals. My goal would be to see more hospitals adopt that model as well, because that would expedite getting to chiropractors earlier. I think historically, we've made our career out of being the last house on the block. I think a lot of the research indicates that we're not only very successful in taking care of chronic pain, but that we're also extraordinarily successful in dealing with some of the acute cases, and if we can catch them earlier, we can probably minimize a lot of problems. The way to do that is through an integrative medicine model, where the vast majority of patients are. Especially the ones who haven't seen chiropractors.

DC: Thank you.

Following our interview with Dr. Milam, Dynamic Chiropractic also spoke briefly with Timothy Treible, MD - an orthopedic surgeon and the hospital's chairman of the board - and Jordi X. Kellogg, MD, to get their perspectives on having chiropractors on staff at Physicians' Hospital, and the role chiropractic plays in the hospital setting.

Timothy Treible (TT): We have developed a new model with regard to incorporating the chiropractic physician community within the hospital's network, both as investors and as physicians interested in providing medical care in a hospital setting. The chiropractic community is highly ingrained within our institution, both within a primary care-type basis as well as within our administrative board structure. We have found that the chiropractic physicians in our community are excellent primary care providers, and are incredibly adept at identifying those patients that require more intensive inpatient care, both within orthopedic as well as neurosurgical referrals. They have also been instrumental in identifying other pathologic conditions that require inpatient medical treatment.

DC: What role do you think chiropractors can and should play in the hospital setting?

TT: In the hospital setting, chiropractic is being introduced as an allied health provider. I envision treatment both on an outpatient level as well as through manipulation under anesthesia, and augmenting our physical therapy modalities of treatment. Additionally, the chiropractic community has expressed eagerness with regard to treatment of those individuals that would benefit from manipulation and other chiropractic modalities, and referral from our soon-to-be-open urgent care facilities. Many MDs and DOs are somewhat reluctant to accept patients that would primarily be treated through physical modalities, but overall, this is an extremely exciting care model that we've created here, and to the best of my knowledge, it's unique in the United States.

Jordi Kellogg (JK): I've been part of Partners in Health for the last couple of years. It's been a nice approach to delivering patient care in an integrative care model, working with different specialists, including chiropractors, neurosurgeons, orthopedists, and medical physicians. It's really been a nice way to bounce things off of each other and try to figure out the best way to approach a patient.

What I've found, working with the chiropractors, is they do great case workup; they really work the patient up well. By the time I see a patient, from a neurosurgeon's standpoint, they've been worked up really nicely. The patients that I see from the chiropractic community are failures, the ones they can't fix. I don't see the successes, obviously, and so they're usually patients that are needing surgical intervention. What I've found also is that with my nonsurgical patients, or patients that I feel should get an opportunity to be treated nonsurgically, I send them to chiropractors, and I've had some really good results. So, it's been a really nice working relationship with them.

DC: What role do you think chiropractors can play and should play in a hospital setting?

JK: I think what it does in the hospital setting, and in Partners in Health, is it allows us to deliver care in an integrative type of care model, where we can work well together. I treat their patients that they can't fix, and they treat patients that I hope to treat without having to do surgery, or I'll send them to the chiropractors following my surgery for postoperative management. It's been a very nice relationship that we've developed, and that continues to develop.

Editor's note: For more information about Physicians' Hospital, please contact Dr. Milam at 800-644-5060.

Michael Devitt is the senior associate editor of MPA Media.

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