30 is the new 45

For years we have been hearing the mantra of baby boomers that refuse to grow old gracefully:  “50 is the new 40,”and “60 is the new 50”…., but researchers in the Netherlands have discovered that in young adults this axiom is not true. Conversely, the current generation of young adults is actually biologically older than their parents and grandparents at the same age. Today’s young adults are so unhealthy that they appear to be 15 years older than their parents appeared at the same age.  The study published in the European Journal of Preventive Cardiology followed 6000 adults over a 25 year period.  This study found that young adults suffered an alarming increase in conditions attributed to metabolic syndrome:  increased rates of diabetes, hypertension, cardiovascular disease, obesity, and other conditions.

According to this study, men in their 30s were 20% more likely to be obese than previous generations, and women in their 20s were twice as likely to be obese as previous generations.

“The more recently born adult generations are doing far worse than their predecessors,” said Gerben Hulsegge of the Dutch National Institute for Public Health and the Environment who authored the study.

“For example, the prevalence of obesity in our youngest generation of men and women at the mean age of 40 is similar to that of our oldest generation at the mean age of 55. This means that this younger generation is ‘15 years ahead’ of the older generation and will be exposed to their obesity for a longer time.”

This study exposes a silent pandemic that is sweeping the developed world; the growing epidemic of ill health brought on by unhealthy eating, obesity, and sedentary lifestyles. In spite of a reduction in risky behaviors, such as smoking, and medical advancements, life expectancies may plateau and actually recede in coming decades.  Certainly the cost of health care can expect to rise, possibly to the point that health care costs could bankrupt the developed world.  Consider some of these chilling statistics:

• $62 billion is the yearly amount spent by Medicare and Medicaid on obesity-related conditions-Robert Wood Johnson Foundation
• $580 billion is the projected economic productivity loss due to obesity that could occur by 2030 if the current trend continues –Robert Wood Johnson Foundation
• $1 billion is spent per year in additional airline costs to cover the cost to fly obese passengers (350 million gallons per year)- Aircraft Interiors International
• $14.3 billion is spent on the cost of childhood obesity in the United States each year-Brookings Institute
• $164 billion is lost in productivity to U.S. employers due to obesity related problems-Society of Actuaries
• One in four young adults are precluded from U. S. military service due to obesity.

What is the answer: More Medicine or More Motion?

Medicine is passive.  The chemicals in drugs may slow the inevitable decline of health suffering from metabolic disease and obesity, but do not address its foundational cause: sedentary lifestyles, unhealthy eating, sleep deprivation, and obesity. More medical doctors, means more pills, but not necessarily a change in the fundamental way we manage health care.

Motion is life.  Chiropractic restores motion and promotes an activated lifestyle. More chiropractors, means more motion.

Mahatma Gandhi - "Be the change that you wish to see in the world."

Treat your patients with chiropractic and encourage them to participate in a chiropractic lifestyle of activity, healthy eating, sleeping, temperance, and healthy relationships. You may also choose to become a local champion in your community to promote an active fit lifestyle and to encourage schools to expand physical education programs.  Finally, I would challenge you to live your life in such a way as to inspire all those around you to greater health and fitness.

Links to References/resources

http://cpr.sagepub.com/content/early/2013/04/08/2047487313485512.abstract

http://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf401318

http://www.aircraftinteriorsinternational.com/articles.php?ArticleID=422

http://www.ncbi.nlm.nih.gov/pubmed/21872750

http://www.brookings.edu/~/media/research/files/articles/2010/9/14%20obesity%20cost%20hammond%20levine/0914_obesity_cost_hammond_levine

http://www.insurancejournal.com/news/national/2011/01/11/180022.htm

http://www.phitamerica.org/News_Archive/10_Flaggergasting_Costs.htm

http://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf401381

The Bucket List,” a 2007 movie starring Morgan Freeman and Jack Nicholson, portrays two strangers who share a hospital room and discover that they have only months to live because of disease. Through a series of events, they become friends and create a list, called a bucket list, of things that they would like to do before they die. Throughout the movie, the two main characters pursue experiences in their fleeting last days, only to learn that the most important things in life are not things.

This movie was a good reminder that the mortality rate for humanity is 100 percent. None of us will be here 100 years from now.

Several years ago, I became very ill and went to a colleague’s office for an evaluation. He is one of the world’s most renowned internal medicine physicians. After a battery of tests and examinations, he told me, “These tests look like those of a patient with non-Hodgkin’s lymphoma. I need you to get some additional tests done.”

He kept talking, but my thoughts jumped to my family and what I had left undone in life: I still needed to teach my daughter to ride her bicycle, I needed to tell my son about the facts of life, and I needed to provide more of a subsistence for my wife. My late father had lymphoma, and I knew what the future held for me.

That next week dragged on forever, and further testing found that I did not have cancer. I had a new lease on life. For the next several weeks and months, I worked hard to mend relationships and to be a better father and husband and a more compassionate doctor. But as time passed, I found myself sliding back into complacency and mediocrity. I had to periodically jolt myself from my complacency and challenge myself to greater things: to love more, to give more, to touch more and to seek God more.

Are You Living to the Fullest?

I would challenge you to examine your existence and the direction of your life. Then ask yourself, “If I knew that I had only one year to live, how would I change my behavior?” If you can honestly say that you would not change a thing, then you are already living life to its fullest. But if you have regrets and remorse, thenI would challenge you to change the way that you are living. Seek greater depth in your relationships, work on deepening the integrity of your character and pour yourself into the service of your patients. You may even create your own bucket list.

While I would not impose on your personal list, I would venture a couple of recommendations for a professional bucket list:

• Go on a benevolent chiropractic mission at home or abroad.

• Mentor a younger doctor.

• Publish in a peer-reviewed journal (this is harder than you think).

• Give hope to a patient who has no hope.

• Pray with a patient for whom you have nothing else to offer but a prayer.

• Cry with a patient.

• Visit an ill patient in the hospital.

• Help someone who can do nothing for you in return.

• Attend the National Chiropractic Legislative Conference in Washington, D. C.

• Raise money for a capital campaign that benefits your alma mater.

• Make peace with an adversary.

Your bucket list should not become just another to-do list. It should be a heartfelt portrait of your professional life—your life as you intended to live it.

Unintended Consequences

Over-reporting and under-reporting of findings

Being able to clearly communicate with patients is one of the skills that patients and other healthcare professions admire most in chiropractors.  Chiropractors have raised the report of findings to an art form.  

Based upon my experience working with medical doctors and chiropractors, I find that chiropractors tend to over-report findings, and medical doctors tend to minimize or under-report abnormal results. (1)  I have a theory for this phenomenon. 

Chiropractors come from a background of treating ambulatory and generally healthy patients.  Abnormal findings and pathology are a relative novelty to the chiropractor, and we are prone to expound on it:  “Mr.  Nelson your MRI shows that you have a Tarlovs cyst, a tear of one of your discs, a benign renal cyst, and some joint (facet effusion) swelling.” (These findings would infrequently be mentioned by a medical doctor to patients.)

Medical doctors come from a [training] background of treating sick patients in hospital settings.  Medical doctors in training may be criticized by their superiors for over-interpretation of findings.  I have seen medical residents and interns scolded for paging their attending physicians after hours with concerns about abnormal findings that the attending did not feel were noteworthy.  The physician becomes comfortable working with abnormal findings, tests, and radiologic studies.  Some physicians allow this comfort level to arise to the point of being cavalier.

According to Casalino, et al. the failure rates of medical doctors to inform their patients of clinically significant test results was 7.1 %, with a range of 0%- 26.2%.(1)    Failure to inform patients of clinically significant findings and to document the results is common:  common and dangerous.  Fortunately this problem has been recognized, and there are systematic steps being taken that should reduce this failure rate.

While medical doctors may have problems with under-reporting of findings, chiropractors may over-report.  I do not have studies to cite the over-reporting by chiropractors, but I know that many of my acquaintances in chiropractic take x-rays on new patients and read a lot of detail into the x-ray report of findings.  Some chiropractors tend use x-rays for practice management as well as a screening for pathology. 

Does early use of radiographic studies adversely affect patient outcomes?

Whether radiographic studies are over-read or under-read is less interesting than the adverse effects of early use of radiology.  Findings from a study by Srinivas et al. tells us that the early use of MRI or other radiographic studies actually leads to worse clinical outcomes in those suffering from back pain. (2)  Another study of work-related injuries revealed that the early use of MRI is associated with an increased likelihood of disability and a prolonged recovery. (3)  Regardless of the interpretation of the radiographs, the simple fact that they were taken seem to affect patient outcomes.  Further study is warranted, but findings like these will be used by decision makers in the reimbursement realm.

How should we interpret this information?

• Make sure that you share all relevant clinical, radiological, and lab findings with your patients and their physicians. 
• Do not over-interpret or extrapolate objective findings.
• Refer to radiographic guidelines. (4)
• Be prepared for third party payers to be even more stringent in approving radiographic studies early in the care of back pain patients.

It is against my nature to withhold even clinically insignificant findings (like benign renal cysts or perineural cysts) from my patients, but I do not want to unnecessarily concern my patients either.  By taking some extra time in sharing information, I find that I can share the findings while putting them in context.  My patients can trust me to share everything with them, and they trust me to know when we need to be concerned.   Communication is one of the qualities that set chiropractic apart.  Take the time to adequately communicate with your patients; it will build a strong relational bond.

(1)Casalino LP, Dunham D, Chin MH, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med. 2009;169:1123-1129.

(2)Srinivas SV, Deyo RA, Berger ZD.  Application of "Less Is More" to Low Back Pain. Arch Intern Med. 2012 Jun 4:1-5. doi: 10.1001/archinternmed.2012.1838.

(3)Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM.  Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers. Spine.  2012 Aug 15;37(18):1617-27.

(4)Bussières AE, Taylor JA, Peterson C.  Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach, JMPT, 2007 Nov-Dec (30) 9, 617-717

Barefoot Running

The Dangers of Groupthink

By William Morgan, DC

The term “group think” was coined by the psychologist Irving Janis in his 1972 work, Victims of Group think: A Psychological Study of Foreign- Policy Decisions and Fiascoes. Group think describes what happens when individual thought cedes to the will of group consciousness. This may sound like a cross between an Orwellian novel and a bad zombie movie, but its prevalence in the world is common, and the dangers of group think are all too real, especially when it comes to decision-making in health care. Group think suppresses dissenting views and can lead to an over simplified view of problems and solutions.

Symptoms of Groupthink
Dr. Janis presented eight symptoms of group think:

• Group attitude of invulnerability. The group feels that it is “bulletproof,” so it takes unnecessary risks and is overly confident.
• Group rationalism—discrediting evidence that is contrary to the group beliefs.
• Group peer pressure inhibits the will to dissent. Members of the group are browbeaten into conformity of thought.
• Group belief of moral superiority.
• Stereotyping of outsiders in negative terms—such as “Oh, he is just a dumb straight.” Or, “Those medi-practors are so insecure in their ability to adjust.”
• Group self-censorship. Peer pressure and stereotyping create a spirit of self-censorship. The team members censor their own words and thoughts.
• Group complacency is fed by the group’s culture of self censorship and peer pressure.
• The appearance of unanimous decisions. Since no one voices a dissenting opinion (because of peer pressure, self-censorship and stereotyping of dissenters), the group feels that it always has a unanimous consensus.

Several failures have resulted from group think: the Maginot Line, the Y2K millennium bug hoax, global warming (both sides of the argument) and the Challenger space shuttle disaster.

In health care, we see group think dangers when treatment risks are considered acceptable by certain specialty groups. Physicians in a group may discuss the nuances of a surgical procedure, but they do not question the need for surgery. Another medical specialty may dispense pain medication while rationalizing the risk-to-benefit ratio. Equally disconcerting are health care administrators and decision-makers who issue decrees for the rest of society while cloistered away in a boardroom far from the treatment room.

Protect Yourself
Of course, it would be hypocritical for us not to reflect on our own profession. Certainly, when chiropractors get together, we can be as guilty as anyone else when it comes to group think. How can we protect ourselves? Whenever we meet in groups, boards or committees, we need to identify the risk of group think and take active steps to prevent its insidiousness from creeping into our midst.

Group leaders should seek input from those with dissenting views.The organization should encourage open discussion and feedback. Having someone play devil’s advocate would also be a way to infuse open thought into our organization.Seeking input from outside the group provides a healthy look at outside opinions. For example, at the hospital, I frequently call upon other physicians for their opinions in complicated cases.Finally, group leaders should avoid stating their opinions so strongly that the entire organization is coerced into marching in lock step with them.

Though Dr. Janis coined “group think” in recent decades, the tendency has been recognized for centuries. Hans Christian Andersen illustrated it eloquently in his story “The Emperor’s New Clothes”, when a little boy broke the trance of national group think by blurting out that the emperor had no clothes. We need to echo the little boy’s sentiment in defending our profession from the ill effects of group think.

Ehlers-Danlos Syndrome (EDS) is not one syndrome but a group more than 10 different congenital disorders characterized by a defect in the production of collagen. EDS can be present as a mild condition that presents with hyperelastic joints, or it can present as a life threatening form that can result in major blood vessel or organ rupture.  Since EDS affects the production of collagen, it can cause increased elasticity and fragility of skin, ligaments, blood vessels, the intestines, muscles, and organs. As chiropractors, we should be particularly concerned with the combined characteristics of hyperelasticity of joints and increased fragility of blood vessels.  The increased propensity for vessel damage and increased motion would increase the danger of causing vertebral artery dissection if a high-velocity low amplitude adjustment was performed on the cervical spine. 

In addition to the increased risk for vascular injury, there is also the risk for dislocation of joints and other joint disorders.  Bracing and stabilization exercises are common treatment for patients with EDS.  There have been a couple case reports demonstrating the safe chiropractic management of patients with EDS through the use of chiropractic adjusting instruments, non-force techniques, postural advice, stabilization, and postural corrective exercises.

EDS is a relatively rare condition, but I tend to get two or three new cases per year (confirmed by subsequent referral and evaluation by our rheumatology department).  It may be that the arthralgia of EDS sends these patients to chiropractors at a higher rate than would be seen by a family practitioner.  For this reason we should be mindful of the diagnosis criteria and management of patients with EDS.

Clinical Presentation

There are a variety of types and levels of severity for EDS, but some of the characteristic findings include:

• Excessive joint motion
• Chronic arthralgia
• Overly elastic, fragile,  or velvety skin
• Fragile blood vessels and organs
• Veins clearly visible under the skin
• Scoliosis
• Fragile eyes that are easily damaged
• Prolapse of the uterus or rectum
• Hernias
• Dental crowding and high palate

The Beighton Score

The Beighton score is based on a series of orthopedic tests that are used to quantify hypermobility and joint laxity found in EDS.  A high Beighton score (6 or greater) is not pathognomonic for EHS, but it would warrant a referral to a rheumatologist.  It is important for EDS to be properly diagnosed and managed medically (by a rheumatologist or geneticist) since there is a potential for life-threatening complications (organ or aorta ruptures top my list of potential concerns for severe cases).

The Joint Commission Now Recognizes Chiropractors as Physicians

Hospital Chiropractic: A Win-Win Scenario?

Before seeking hospital privileges, consider what you can offer.

By William Morgan, DC

Many of the chiropractors who contact me, have misconceptions about the benefits of hospital affiliation and are often using flawed strategies when pursuing hospital privileges. Receiving hospital privileges is not the answer to one’s practice management concerns. Moreover, chiropractors should recognize that hospitals also need to realize a tangible benefit from allowing DCs on staff.

Hospitals and medical centers have changed tremendously in the past few decades. There was a time not too long ago when patients would stay in the hospital for weeks following back or neck surgery, childbirth, hernia surgery and other procedures with prolonged healing periods. But that practice has changed; currently physicians strive to send patients home as soon as they can safely do so. In this new environment of hospital care, only the very sick or severely injured stay in hospitals more than a couple of days. This new paradigm of hospital care makes it less likely that a chiropractor affiliated with a hospital will have admission privileges—privileges that allow a provider to admit patients into the hospital.  

What Can the Hospital Do for You?
Although chiropractors will probably not admit patients, they may still co-manage cases or consult admitted patients while collaborating with the admitting physician. Chiropractors are not alone; many emergency room physicians, radiologists, public health physicians, optometrists and psychologists work in hospitals without admission privileges.

The real benefit of a hospital-affiliated practice is access to outpatient services and the advantage of collaborative specialty care for the patients. This level of interaction typically yields the fruit of increased cooperation and inter-specialty referrals with physicians.

What Can You Do for the Hospital?
Most chiropractors intent on obtaining hospital privileges are so obsessed with the credentialing process that they neglect to create a profitable model for a hospital-based practice. Hospitals, even nonprofit hospitals, want to see a profitable practice model before they expand services. There must also be a demonstrable benefit to the facility and to the patients for expanding hospital services to include chiropractic. Before approaching a hospital, you should consider what you have to offer. How will you increase the hospital’s care and help its bottom line? Will you attract more patients to its Spine Center or Pain Clinic?  Will your practice attract more patients to the hospital’s ancillary services like radiology, laboratory, physical therapy, pharmacy or wellness programs?

Demonstrate Your Value
Once a hospital wants you on staff, it will handle the credentialing and privileging process. There is little reason for chiropractors to pay for training in hospital credentialing. More important is creating a profitable model of care that will make a hospital want you on staff. If the hospital cites credentialing or scope of practice difficulties as the reason that it will not admit you, it is actually because it does not want you in the hospital. It means that you have not overcome objections by naysayers or you have not shown a perceptible improvement in patient care and utilization. 

To gain access to a hospital you need to win over the naysayers, establish working relationships with other professions that would be enhanced by a hospital affiliation and show that the hospital would realize a net gain by your presence. This normally takes time, energy and hard work. 

Improving Productivity

Out of time, again? Try these 9 tips for reclaiming your day.

By William Morgan, DC

Whether you work in an integrated environment or a stand-alone clinic, the world of health care requires you to be more and more productive with your time. My goal has always been to use technology and discernment to make my workday more productive and free up more time for my family. Below are a few things I’ve learned over the years.

Have a Web site

Stop answering the same questions over and over. And stop repeating the same patient instructions. Use a professional Web site to share information about you with your patients and your team of integrated physicians. My staff automatically sends links for our Web site’s back- and neck-care presentations to all new patients (after obtaining a written authorization to share non-personal healthcare information via e-mail). Defer to your Web site for sharing much of the information about you and your clinic’s policies.

Streamline Your Correspondence

In a clinic that interacts with referring physicians, do not reinvent the wheel every time you send a report of findings or a clinical update. Save form-letter templates in your computer and just change the portions required to communicate what is happening with that patient.

Get an Extra Computer Screen

Several surveys have shown that an extra computer screen attached to your comper can make you up to 42 percent more efficient. Newer computers allow two or more monitors to be used from one system. As I write this article, I am using two screens: on one screen I am typing this article, while on the other I am reviewing surveys and other articles about this topic. Try it; you’ll love it!

Get a Third Screen

Two is good, but three is better. Adding a third screen may require installing a graphics card into your computer.

Read Your E-mail Twice a Day

Compulsively checking e-mail or surfing the net is one of the great time sumps of the computer age. Try to limit your time responding to e-mail. When you do respond, use polite, short notes. If an e-mail requires more than two paragraphs, pick up the phone instead.

Cancel Cable TV

My wife and I have never subscribed to a cable service, and I guarantee we haven’t missed anything. Instead of watching TV or playing computer games, do something productive or interactive with your family or friends.

Use Mass Transit

I take the train and bus to work whenever I can. This allows me to turn my commute time into productive time. I try to have devotional time on the commute to work. On the return trip, I try to create productive time by reading and using my laptop. Mass transit is also good for the planet.

Don’t Try to Impress People

Much of our time is spent trying to impress people. Buying fancier cars, houses or boats requires more money. More money requires more work. Learn to be satisfied with what you have. The new definition of being wealthy is not having more possessions; rather, it is having more time and mobility.

Don’t Over Commit

Just say no! Say no to things that are unproductive. Ironically, it’s frequently small commitments that gobble up time: the letter of recommendation, visitors interrupting your administrative time, the committee membership. You owe it to your patients, your staff and your family to be a good steward of your time and focus.

The Secret to Turning a Multidisciplinary Clinic into an Interdisciplinary Clinic

By William Morgan, DC

Managing patients in a multidisciplinary clinic, such as a spine center, is usually done in a somewhat haphazard manner. The patient enters the clinic by referral or through direct access to one of the providers. The provider could be a chiropractor, neurologist, orthopedist, PMR or any number of specialists. This initial provider has first right of refusal regarding whether to treat or refer the patient. When and if the first provider feels it is appropriate to refer a patient to another discipline, he or she will select the next specialty to be tried. This method of case management is really a “daisy chain” of successive treatment trials rather than a thoughtful and deliberate synchronization of care.

This type of management reduces the synergy of being interdisciplinary to merely being multidisciplinary. Simply having a variety of different specialties together does not make a clinic more proficient. An interdisciplinary clinic has an organized method to maximize the effectiveness of treatment using various specialties in concert.  In contrast, a multidisciplinary clinic simply has different disciplines of care available—but no coordinated approach to that care.

The Case Manager 

The case manager helps the referring provider or patient to select the best provider to initiate care, and then follows that patient’s case to completion. The case manager is usually a mid-level provider such as a RN, FNP or PA.  The case manager ensures that appropriate outcome measures are initiated during the preliminary visit and at regular intervals. The results of the outcome measures may be used to modify care. The goal of the case manger should be to reach a point of case completion (see Case Completion, ACA News, May 2005, pg. 10). While the provider works toward case completion, the patient’s care should gradually shift from passive to active care.

The case manager will shepherd the patient through the most conservative care that is appropriate for that patient’s condition. Frequently, the most conservative care for a patient will be chiropractic. However, if a patient presents with something more ominous, such as a conus medularis syndrome, then a neurosurgical consult would be the most conservative care appropriate.  

Creating the Case Manager Position

When creating a case manager position it is important to empower the manager with the tools to operate efficiently, while providing guidelines that are well defined and reflect evidence-based and safety-minded algorithms.

The case manager is tasked with maximizing the use of outcome measures, flow charts, progression from passive to active care, and patient follow-up.  The case manager sends periodic and regular reports to third parties, and facilitates interdisciplinary communication.  The manager should feel comfortable in seeking consultations from various providers, as needed.

Solidifying the Team Approach

Regular meetings with the different clinic specialties and the case manager will ensure that patients receive the most appropriate care and will provide an additional layer of safety and reflection. This will also give the clinic a chance to improve efficiency by coordinating care: graduating from passive care to the active care of rehabilitation and ensuring that ergonomic evaluations, back school, and wellness programs have been implemented.  

The case manager ensures that outcome measures are completed regularly and utilized in decision-making (i.e. deciding if the patient’s condition is permanent and stationary or if the current line of treatment has reached maximum effectiveness and another treatment should be utilized) and that appropriate reports are completed. The case manager will also see that referring providers are kept apprised of the patient’s progress and that third-party payers receive adequate and appropriate clinical appraisals. 

In conclusion, the case manager’s work will ensure that patients receive the most appropriate interdisciplinary care possible until the case is completed.