Hint: It is not CE

Continuing education may be replaced with a new model of life long growth: Continuing Development.

There is certainly a need to ensure that doctors remain competent and their knowledge current after graduation.  But what is the best way to do this?  In an attempt to ensure that doctors remain competent, and that they stay abreast of current trends and advancements, licensing boards began several decades ago to dictate a prescribed number of approved continuing education (CE) class hours. But the required CE, in the form of formal didactics, is often disjointed from clinical practice.  CE is often a class taken by a doctor over the weekend with the hope that some of the new knowledge may be implemented into practice on Monday morning.

Built In, Not Bolted On

Continuing development (CD) or continuing professional development (CPD) by contrast is a system intent on developing several core competencies and engraining them into the practice of the physician.  CD has a goal of changing behavior and improving clinical outcomes.  CD is a journey that, if done correctly, will last a lifetime and will engage the physician to learn and grow on a daily basis.  

You Can Lead a Horse to Water, but…

Regardless of the intent and implementation of a continuing development program, it will fall short of its goals if the individual doctors are not invested in the process.  The motivation for professional development must come from within the individual doctor.  We can encourage doctors to pursue CD and to honor its concepts, but ultimately the responsibility rests squarely on the shoulders of the physician.  Rules and regulations will provoke a physician to obey the letter of the law, but cannot ensure total compliance.

Characteristics of successful lifelong learners in clinical practice include:

• The drive to be a master clinician and to provide excellent patient care
• The pride in the enduring value of professional competencies and scholarly growth
• The need to expand and grow in knowledge and clinical application

Continuing development requires the heartfelt desire to grow and blossom throughout a career. Doctors must embrace the concept of lifelong learning and be knowledge seekers.

This stands in contrast to passive learning.  Passive learners sit in a classroom and are taught, they are directed what to read and what to study.  They do what is required of them without seeking to learn more.  Passive learners can be straight A students and may be difficult to differentiate from active knowledge seekers in the classroom setting.  How can we inspire passive learners to become active knowledge seekers?

Master Clinicians

The Role of Chiropractic Colleges

Chiropractic colleges should use criteria to identify lifelong learners and actively attract and recruit these knowledge seekers.  Colleges should also inspire students to continually seek knowledge rather than regurgitate lectures or board review material.  They should introduce students to the tools that they will need to continue to learn and develop throughout their career.  As students approach graduation, classroom-based didactics should be replaced with active clinical rotations which require students to seek knowledge while clinically active.  This should translate to doctors in the field who continue to grow and learn daily through clinical encounters.  Daily learning in the student clinic should be a model for daily learning throughout a chiropractor’s career.

Continuing development has many benefits for the doctor, the patients, and society.  The doctor benefits from career satisfaction, and patients benefit from superior healthcare.  A doctor who is continually being challenged is less likely to suffer from burnout.

Clinical Mastery

Informed Consent: The Ceremony

Time is Tissue

When a stroke or heart attack occurs, rapid response is needed to prevent catastrophic damage.  In the case of a cerebrovascular accident (CVA), there is a critical golden hour in which particular clot busting drugs must be initiated to minimize permanent brain damage.  Every moment that treatment is delayed, further tissue damage occurs.  Quite literally time is tissue; the longer treatment is delayed, the more tissue is destroyed.  Once a CVA or myocardial event occurs the clock begins to tick, and the patient needs to be treated as soon as possible to prevent major irreversible damage.

Patients may be compelled to visit a chiropractor’s office for treatment of neck pain, dizziness, or severe headaches when they are experiencing the early symptoms of a stroke.  It is paramount to identify stroke patients and get them to an emergency room (preferably a comprehensive stroke center) as soon as possible.

Be prepared in advance for an ischemic event.  Know which medical facilities are best equipped to treat a CVA and keep their number accessible. Alert your staff to inform you immediately of any patients entering your clinic with signs or symptoms of an ischemic event.  Teach your staff to be able to identify the tell-tale signs of a stroke:  weakness or one sided paralysis, speech problems, facial muscle weakness, drooling, numbness, balance disorders, difficulty swallowing or visual disturbances.

Be proficient in quickly performing a neurological exam assessing motor strength, cognitive response, reflexes, and cranial nerves.   If a CVA is suspected, initiate an emergency response: call for emergency medical transportation.  Do not adjust a patient you suspect is having a CVA.  Call ahead to the medical facility and explain your observations to the staff.  This will save time in initiating care. If the symptoms of a CVA started after an adjustment, make sure that you share this information. 

It is a mistake to delay care.  Do not have the patient wait while you monitor their condition.  Remember time is tissue.  Every minute that emergency treatment is delayed increases the likelihood of irreversible brain damage. A CVA is a medical emergency call 911.

Identifying and Minimizing Stroke Risks

Ischemic cerebrovascular events are the third leading cause of death in the United States.   There are well established risk factors for ischemic CVAs that can be identified by a dutiful practitioner:  Smoking, diabetes, high blood pressure, obesity, sedentary lifestyles, arterial disease, the use of birth control pills, heart disease, and stress. People over 65 account for two-thirds of strokes, men have more strokes than women, and African Americans have a higher rate than Caucasians.

Promoting wellness lowers the risk of stroke.  Partner with your patients to help reduce their risk of stroke.  Encourage them to limit salt consumption, quit smoking, to exercise,   maintain a healthy body weight, improve their diet, and consult their physician about alternatives to the use of oral contraceptives.  It may be that promoting an active mobile lifestyle through chiropractic may be one of the best ways to promote vascular health.

The Spine Center

One of the more exciting recent developments in healthcare is the formation of Healthcare Service Lines.   The Service Line concept creates a multidisciplinary one-stop-shop.  One good example is breast care centers.  Breast care centers place internal medicine, surgery, radiology, oncology, social work and physical therapy in one convenient location.   The patient has all of her breast care provided by a co-located team of professionals. 

The Spine Center is a naturally good fit for chiropractors seeking to join an integrated service line.  These centers combine various spine related specialties.  The specialties may include neurosurgery, orthopedics, PMR, pain, chiropractic, psychology or psychiatry, physical therapy and patient education specialists.

In a spine center, the whole is greater than the sum of its parts.  The advantage of forming a multi-specialty clinic is not just having a bigger “box of tools,” but is the wise use of each “tool.”   Subsequently the hallmark of a great center is its patient management.  A well-managed specialty center will make sure that patients are referred to the appropriate provider(s) early, and that conservative methods are exhausted before the patient is seen by an interventional specialist such as a surgeon.   Selecting the proper case managers is key in having a successful spine center.   Physician assistants and nurses are commonly used as case managers, but chiropractors are extremely well suited to be case managers.    

Two models are commonly used to manage patients in spine centers.  In one model patients are screened by a case manager when they enter the clinic.  The case manager then directs the patient to the most appropriate provider, usually conservative care such as chiropractic. In the second model of case management the patient enters the clinic through any of the clinic’s direct access providers.  That provider may initiate care or refer to one of the other specialties.  The portal of entry provider may orchestrate future care of the patient or defer this task to a case manager.  In either case, decisions should be based upon an evidence-based algorithm of care.

For complex cases a focus-group approach is used.  Gathering together as a group at a round table (or more commonly, informally in the hallway) physicians will discuss more difficult cases and plan more complex and integrated treatment programs.   At our hospital we can use our secure internet for group discussions.  We use digital MRI, CT and X-rays so our emails can include the patient’s radiographic imagery. The patient benefits from the combined efforts of several specialists.

Complex cases may require synchronized use of different specialties.  Our patients may be under the active care of a surgeon, chiropractor, physical therapist and behavioral health specialist simultaneously.

Chiropractors should be included in every progressive spine center, however if you are not able to join a spine center, you can create a virtual spine center by establishing alliances with other specialties.  You would be a portal of entry and the primary center for conservative care and would refer to interventionalists for evaluation, consultation or treatment when appropriate. 

Creating a spine center can be a win-win relationship for everyone involved: the patients win because they enter into a multidisciplinary clinic that should have the best treatment for them; the providers win because they will have an ample amount of appropriate patients.  Chiropractors can treat with chiropractic and not have to dabble in someone else’s specialty; other professions in the clinic likewise will practice within their specialty and not dabble in chiropractic.  Moreover, a well-run spine center will reduce the number of unnecessary surgeries, prescriptions, and redundant services.

Integrative Schizophrenia

With increased national interest in Complementary and Alternative Medicine (CAM) the government is now evaluating and researching the various alternative forms of health care.  This attention carries with it the potential for research grants and other sources of government funding.   In the past chiropractic has been strongly identified with CAM, but in recent years chiropractic has been drifting from the fringe and moving toward a place in mainstream healthcare. 

The Chiropractic profession is now betwixt and between, not fully mainstream and not fully CAM.  Unquestionably there are chiropractors who bear a resemblance to being a medical subspecialty, but there are also chiropractors who are as alternative as any shaman.  It seems that chiropractic sways to and fro, according to which title provides the greatest benefit at the time.

Should chiropractic be lumped together with alternative medicine disciplines such as sweat lodges, Reiki, color therapy, light therapy, herbology, iridology, touch for health, aura therapy, magnetism, polarity, colonics, aroma therapy, chelation, visualization, channeling, faith healing, healing crystals, etc?   Or should chiropractors be grouped together with physiatry, occupational health, orthopedics, or pain management?  There are benefits and pitfalls to each.

As a profession, chiropractic appears to be schizophrenic: We want to be CAM when it comes to receiving financial rewards earmarked for CAM, but we want to be mainstream when it comes to benefits set aside for manual medicine.  One day we may need to make a commitment to become either CAM or mainstream. 

Alternative extremes

Some CAM practitioners are opposed to anything linked to western healing, including Hippocrates’s views of healing, and will embrace everything that is counter to medicine regardless of its merit.   When one takes this stance he could be viewed as a social activist as well as an alternative healer.  Being lumped with all sorts of alternative healing arts, especially absurd or fringe arts, will damage chiropractic’s credibility.

The peril of being a specialty of mainstream healthcare

Having a uniquely chiropractic profession gives us the latitude to think differently than other professions.  Having a non-medical, non-surgical orientation is an advantage and certainly not a drawback.

One of the dangers of integration, especially by fledgling chiropractors, is the acquisition of a strongly medical orientation.  Chiropractors with a strong medical orientation may lean so far to the mainstream that they exclude chiropractic’s emphasis on natural healing and avoidance of unnecessary medication.

Public bewilderment

When you go to a medical office, you can expect to see constants in care.  Most offices will begin care with taking vital signs, a patient interview, and an exam.  A diagnosis will be rendered and a treatment proposed.  These constants are present in virtually every medical clinic in the country and familiarity with these constants reassures patients.

Chiropractic by contrast has a variety of treatment techniques, claims, philosophies and technologies.   These range from mainstream to peculiar. These variations are confusing to the public and to other professions.   When patients share their chiropractic experiences with each other, they must question whether or not they are even talking about the same profession.  To rephrase a Forest Gump quote, “Chiropractic is like a box of chocolates, you never know what you are gonna get until you look inside.”

Striking the Balance

Most modern chiropractors maintain wellness practices with a strong emphasis on musculoskeletal (MS) care: 90-95%[i]^{,[ii],[iii],[iv]}  of chiropractic patients are treated for MS conditions.  Promoting healthy living while avoiding a dependence on unnecessary drugs is not fringe, it is what most patients prefer.  This model of chiropractic is mainstream, not CAM.  Conversely, obsessively clinging to fundamentalist doctrines regardless of burgeoning evidence is CAM.

As more and more chiropractors embrace integration, consistency of care should follow. Contemporary chiropractors are constant in their inclusion of vital signs, patient interviews, informed consent, orthopedic, neurological and regional exams, a diagnosis, and treatments that include manual treatment, exercise and patient education.   Profession-wide consistency in practicing evidence-based chiropractic may be the solution to our current state of societal puzzlement regarding chiropractic.

Pride and Prejudice

As much as I hate to admit it, my favorite fictional work is Jane Austen’s classic Pride and Prejudice.   It portrays the lives of the gentry in eighteenth century England with the two main characters beset by mutual misunderstandings and misconceptions about each other.  Pride and Prejudice refers to the manner that the feisty Elizabeth and snobbish Darcy view each other.  As the story unfolds they each realize that their pride and prejudice has blinded them to the deep qualities and character that is embodied in the other.   As they overcome their own pride and prejudice, they realize their mistake and fall hopelessly in love.

I present to you that Pride and Prejudice, the character flaws, not the book, have created most of the interdisciplinary strife that we see affecting the practice of healthcare.  The pride of one profession boasting its superiority over another; the prejudice that another profession is in some way inferior has created great divisions that have inhibited integration and synergistic patient care. 

Professional Bias

We all have it, the belief that we are in some way superior to other professions.  After all, look at all of the patients you helped that the physical therapist, surgeon and pain clinic treated and did not help.   What about all of the patients who got worse under traditional medical care?    The fact is that you may rarely have seen a patient helped by another profession.   Why should you?  The patients who got better never came to see you.  The same is true in regard to how other professions view you.  They never see a patient that you heal.  They only see your failures, so they believe that you do not help anyone.  After all, how often does a well patient walk in to a medical office to tell their doctor that the chiropractor cured them?   Studies by Dr. David Eisenberg have revealed that most people do not even tell their physician that they see a CAM provider such as a chiropractor.

If we were to base our beliefs solely on the patients who walk in our doors, we would conclude that spine surgery never works and physical therapists continue to have patients schedule long drawn out treatment programs without benefit.  Unfortunately, that is just what happens.   Professional bias views the world in a myopic manner, developing unfounded prejudices.   These prejudices impede professionals from implementing the best approach for most conditions: the interdisciplinary approach.

Humility and Open Mindedness are the Remedy

“Every man’s way is right in his own eyes.[1]” This ancient biblical quote illustrates that bias is an age old concern.   We are all biased and need to be held accountable for our predispositions.  By humbling ourselves to a peer review process and to allowing our dearest beliefs to be challenged in an intellectual manner we can over come our prejudged beliefs.    I recommend joining or forming a multidisciplinary Journal Club.   This will not only help you overcome your bias, but will help other specialties to overcome their biases about chiropractic.  Some of the spine specialists at our hospital have formed a very social journal club that not only analyzes and reviews journal articles, but has solidified an interdisciplinary referral network.   The club meets once a month at a restaurant and has helped to create friendships among open minded colleagues.

Cross pollination in training chiropractic and medical students is another way that we can overcome bias.   When chiropractic students interact and work with medical students while performing hospital rotations, both groups are changed and old biases are done away.  This type of cross pollination can prevent a lifetime of misunderstanding and bias.

Another way to overcome medical prejudice is by sending progress reports to patient’s physicians.   Every specialty sends progress notes back to the patient’s primary care manager (PCM).  Chiropractors should too.  Use standardized outcome measurement tools to honestly appraise the patient’s response and to inform the patient’s PCM.   This should introduce the PCM to the types of responses that can be expected when he refers to a chiropractor.

In Pride and Prejudice Jane Austen uses irony to entertain her readers.  In real life it is ironic that chiropractic is both the victim of prejudice and the perpetrator of prejudice.  As the chiropractic profession matures we need to purpose in our hearts to overcome our own prejudices and to seek to end the prejudices and bias beset against us.

The Collapse of the Railroads (What business are we really in?)

At one time the railroads were the most powerful companies in the United States, they controlled vast tracks of land, money, politicians, and much of the transportation in our country.   Over that last century these mega companies have recessed to struggling relics, shells of their past might.  They have lost their prestige and now struggle to maintain relevance.  What happened to the railroad companies? 

The railroad companies did not realize that they were in the transportation business, not the railroad business[1].  When other forms of transportation evolved, instead of embracing these trends and growing with them, the railroads resisted.  Had the railroad companies realized that they were actually in the transportation business, they could have integrated highways, trucks, autos and fueling stations into their already powerful business.  What caused the demise of the once powerful railroads?  They were product orientated, not customer orientated.  They wanted to dictate what the customer needed, not listen to what the customer wanted.

What business are we really in?

Some would say that chiropractors are in the subluxation business or the adjustment business.  This is not true; we are in the healthcare business.   Providing adjustments is a product-oriented business rather than a customer-oriented business.  Patients are motivated to come to providers to enhance their health and to avoid pain or discomfort.  The adjustment may be the means to that end, but it is not what is sought by patients.  Pain relief and wellness are their goals.  

A while ago I spent a couple days observing a chiropractor friend.  He has a very conservative subluxation-oriented practice replete with all of the associated patient education material.  As I watched him interact with his patients, he continually reinforced his beliefs on the philosophy of chiropractic and wellness to his patients.  But as I observed these interactions I was surprised to discover that not one patient entered that practice simply for wellness.   They all had musculoskeletal complaints.    No one was listening to his philosophy, they were still seeking relief.  There was a communication disconnect in this practice:  he provided a product orientated service, while his patients continued to use him to meet their customer centered needs in spite of his intent.

Society for the most part does not know the differences between subluxation from subjugation.   But they do know what they want: mobility, relief of pain, increased athletic performance, and a hope for a more fulfilling and healthy life.  Judging by the conditions treated by chiropractors, a decided majority of chiropractic patients are being treated for musculoskeletal complaints.[2]^{,[3], [4], [5]}  Our patients have decided that we are primarily in the pain relief business not the wellness business.  Only 5-10% of our patients are being treated for non-musculoskeletal complaints or wellness.   Our society has spoken; to them we principally treat musculoskeletal conditions.  Are we listening? These patients will seek out the caregivers who will meet their needs.   Will chiropractors be the providers they seek? The increased chiropractic interest in rehabilitation, orthopedics, and myofascial techniques such as Graston and ART points to a shift in meeting the wants of society.

True wellness care is not limited to the chiropractic adjustment, but in combining chiropractic with an active lifestyle, weight control, exercise, prudence, temperance, smoking cessation, proper nutrition and hydration, proper sleep habits, stress management and routine wellness examinations.  Our patients would like for their providers to work together with the mutual goal of wellness.  Comprehensive wellness and integrated care is not the enemy, it is the future.  If we wish to remain relevant, we need to value what the population desires, rather than what we want to sell them.    If we continue pushing the product rather than listening to the customer, we will duplicate the business model of the railroad companies.

Chiropractors as Personal Trainers?

As I scan the internet and my online contacts I have become increasingly aware of a significant number of chiropractors who are also promoting themselves not just as chiropractors but also as personal trainers and fitness coaches.  At first I thought that these doctors were trying to supplement a fledgling or struggling practice with additional income.  But as I look closer I see that for many this is an emerging practice model for chiropractors:  the fitness/health coach model of care.

I have spent my career in chiropractic by treating patients in my office or hospital.  While I recommend programs of broad-based fitness, I do not typically follow my patients to the gym.

Good fitness advice is hard to come by, and if the trainers at two of the three gyms (don’t ask why I train at three gyms) at which I train are any indication, most personal trainers are offering dangerous advice and ill-conceived exercise programs.  I am constantly biting my lip when I see personal trainers have their clients perform some of the stupidest exercises imaginable:  trunk twisting with barbells or dumbbells, bent at the waist twisting with a barbell on the client’s back, deadlifting with a curled (flexed spine), sit-ups, clean and jerks with curled spines, and all sorts of bizarre renditions of exercise.

In contrast to the gyms with low-level trainers, one gym at which I train at has master degree level trainers who are Certified Strength and Conditioning Specialists (CSCS) certified trainers. These trainers are stellar, and I am inclined to seek advice from them and trust them with my patients.   There is a niche for well-informed and educated trainers with a leaning toward function (versus muscle isolation).

What are the Qualifications for Personal Trainers?

While there are varying credentials for Personal Trainers, some arduous, others not so difficult, the minimum requirements are relatively low: a high school diploma and a short vocational course of study, possibly a certificate, but not licensed.  I should note that some fitness employers require trainers to have a bachelor’s or even a master’s degree.  According to the U.S. Bureau of Labor Statistics in 2010, the average wage for a personal trainer was $31,090/year.

Since the qualifications for a personal trainer are so much lower than for a chiropractor, I see the advantage for chiropractors to differentiate themselves from the trainer who has just a high school diploma and a short vocational course of study.  I also see a credibility disadvantage for any chiropractor equating their credentials with those of a personal trainer.  For this reason I recommend that if you are going to use this practice model, consider sitting for the CSCS examination.

Chiropractors are allowed to sit for the CSCS examination through the National Strength and Conditioning Association.  This certification is difficult, but the credential of CSCS will set the chiropractor/fitness trainer far above the certified personal trainers with minimal vocational training. Another professional level fitness certification is the Registered Clinical Exercise Physiologist credentialed through the American College of Sports Medicine. 

The Exercise Prescription Beats the Drug Prescription

Certainly the health effects of exercise are superior to virtually any drug on the market.   If a drug company could bottle the health effects of a sound fitness program, their stocks would go into the stratosphere.  But they cannot. 

Six of the ten leading causes of death are related to obesity and lack of exercise.  Chiropractors need to promote broad-based fitness to their patients if they want to maximize the health of their patients.  This does not mean that they need to personally supervise every workout in the gym.  If you choose to personally supervise patients in the gym, I recommend that you set your mark on the highest fitness credential that you can obtain.