Patients Who Need Treatment Beyond the Spine

posted by Lori Holt in Risk Management on April 13, 2017

Many D.C.s coordinate their patients' overall healthcare and see patients with conditions not traditionally associated with chiropractic care. We asked Dr. Konarski-Hart to share her perspective on this trend.

By Karen Konarski-Hart, D.C.

Regardless of preferred focus of treatment, D.C.s need to address problems beyond the spine that are revealed through the history or exam. This is necessary for the patient’s well–being, as well as the doctor’s risk management.

In the CCE Accreditation Standards, Principles, Processes & Requirements for Accreditation (January 2013), the preface states: An accredited DCP prepares its graduates to practice as primary care chiropractic physicians and provides curricular and clinical evidence of such through outcome measures. To practice as a primary care chiropractic physician, DCP trains its graduates to:

  • Practice primary health care as a portal-of-entry provider for patients of all ages and genders focusing on the inherent ability of the body to heal and enhance function without unnecessary drugs or surgery.
  • Assess and document a patient's health status, needs, concerns and conditions with special consideration of axial and appendicular structures, including subluxation/neuro-biomechanical dysfunction.
  • Formulate the clinical diagnosis(es).
  • Develop a goal-oriented case management plan that includes treatment, prognosis, risk, lifestyle counseling, and any necessary referrals for identified diagnoses and health problems.
  • Follow best practices in the management of health concerns and coordinate care with other health care providers as necessary.
  • Focus on neuromusculoskeletal integrity for the purpose of enhancing health and performance.
  • Promote health, wellness and disease prevention by assessing health indicators and by providing general and public health information directed at improving quality of life.
  • Serve as competent, caring, patient-centered and ethical healthcare professionals and maintain appropriate doctor/patient relationships.
  • Understand and comply with laws and regulations governing the practice of chiropractic in the applicable jurisdiction. 

I believe more patients are viewing D.C.s as primary care physicians (PCPs) because:

  • There is a greater interest in alternative and natural healing.
  • It can be easier to rapidly obtain an appointment with a D.C. than a medical primary care provider, especially in rural areas where physicians are in short supply.
  • Many patients want to be active participants in their healthcare and prefer D.C.s who are typically more open in their communication style.
  • Patients with limited financial resources may prefer to see only one doctor.

Considerations for Different Practice Types

Some D.C.s identify and treat non-neuromusculoskeletal (NMS) problems by performing imaging and lab work, integrating nutrition, acupuncture or lifestyle counseling with adjustments. They refer patients for co-treatment as needed.

Other D.C.s focus only on spinal conditions. Regardless of your practice style or philosophy, patients must be informed and understand which health problems are being addressed by their D.C. and be referred to other providers as their conditions dictate. Factors that will help you determine which aspects of patient care would be best handled by you include:

  • Patient’s condition and consent
  • Your practice’s style, rapport with patients, and the state’s and your personal "scope" of practice
  • Patient’s insurance coverage

Preparing for the Non-NMS Patient

Often, in a busy practice, the details of a patient’s history can be easy to overlook. Medical gatekeepers, insurance restrictions and difficulties in accessing specialists can complicate coordination of care for a non-NMS patient. Here are steps I’ve found beneficial in this regard:

  • Review your processes. Check patient intake and history forms. How are non-NMS notations handled? Are they discussed with the patient? Are lifestyle habits such as smoking and fitness addressed?
  • Update your knowledge by reading medical and chiropractic peer–reviewed journals, taking web courses, and perusing peer-reviewed online resources. College and state associations may also offer programs on non-NMS issues, and many chiropractic diplomate and specialty programs include modules in laboratory analysis or viscera diseases. Community meetings, health fairs or interdisciplinary forums also may provide insights.
  • Prepare through networking. In addition to partnering with medical practitioners, consider consulting with and referring to other D.C.s or to non-medical providers for specific treatments. For example, patients with mental health concerns, chronic pain, weight control, exercise or sleep habits may benefit from the help of another professional. Calling another provider is always easier when you have a rapport with that person. Any interaction, such as working on an interdisciplinary board or a community health project, makes future contact more comfortable.
  • Contact the provider (assuming it’s not an emergency situation). Preferably, the patient will be present during this conversation so any appointments and advice can be documented. Otherwise, request the patient contact his physician as soon as possible. Then, follow up with the patient to ensure compliance and document outcomes.
  • Document the discussion and consider obtaining the medical records, if appropriate. If you have suggestions, encourage patient discussion with you and the treating physician. (Of course, never recommend a patient discontinue taking a prescribed medication.) Make sure to document the patient’s understanding of the importance of compliance.

A graduate of National College of Chiropractic and fellow of the Academy of Chiropractic Orthopedics, Dr Konarski-Hart has served as president of the Arkansas Board of Health and as commissioner/councilor of the Council on Chiropractic Education. She holds a master's degree in Disaster Preparedness and Emergency Management from Arkansas State University. She is the vice president of the American Chiropractic Association and a member of NCMIC’s Speakers Bureau.

This article appeared in NCMIC’s Examiner magazine, a publication for NCMIC policyholders with compelling case studies and practical tips for avoiding a malpractice allegation. View the current issue of Examiner for more case studies and articles.

The information on this page is offered solely for general information and educational purposes. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care. You should not act or rely upon this information without seeking the advice of an attorney familiar with the specific legal requirements of the state(s) in which you practice. If there is a discrepancy between the site and an insurance policy you have with NCMIC, the policy will prevail.

About The Author
Lori Holt

Lori Holt, RN-BC
Professional Relations Representative - NCMIC Insurance Company

Lori Holt joined the corporate relations staff in 2012 and hit the ground running - literally - as she travels to various colleges and state associations to present on risk management and office emergencies. She also assists at homecomings and other events where NCMIC has a presence. Lori was bor ... read more

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Handling an NMS Patient … How would you handle the following scenario?

An overweight 50–year–old female presents with neck stiffness from prolonged computer work. She recently has had nauseating headaches that wake her at night. She has no history of spinal trauma. Two of her sisters have type 2 diabetes, and her mother died at age 55 of a heart attack. The patient wears over–the–counter reading glasses. She has no exercise routine but says she gets enough exercise by getting up and down at home and at work to try to relieve the tingling in her feet. When she gets up, she usually walks to the bathroom since she sips on Coke all day to stay alert.

While there is no “right” treatment or approach, given this patient’s personal and family history, there is a high index of suspicion for type 2 Diabetes, and I would discuss my concerns with the patient. I also would review the options available, supply the patient with information sources, and document the decisions and referrals made. Referral letters and requests for test results would be kept with the patient’s signed release.

What other information, system analysis or consultation might be considered beyond the chiropractic examination? Depending on further exam findings, the state’s scope of practice, available local resources and on-site treatment available, I would consider ordering other procedures myself, referring the patient to the primary care physician, or sending the patient to a specialist directly.

I would address lifestyle changes–such as diet, exercise and weight control–and maintain an updated list of the patient’s supplements and pharmaceuticals.

Fostering a “team” approach can help focus on the well-being of the whole patient and protect against a missed diagnosis.

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