Triaging Cases in Contemporary Chiropractic – Mark Studin DC

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Hi, I am Dr. Mark Studin, and first, I’d like to thank ChiroSecure for giving me the opportunity. To share today’s information with you. There is so much going on in the chiropractic industry right now with respect. Actually, there’s never been a better time in our history to be a chiropractor than today.

It’s just exciting. But there are pitfalls and our minefields, and if you play by the rules, you’ll never have a problem. But you have to understand those rules and actually, Many of those rules were taught to you in chiropractic college, and too many of us forget what we learned. We cut corners, we get lazy.

So we’re gonna go to the slides now and give you a little insight into one of the things. That is a huge pitfall right now, and it’s called predetermined treatment plans. Predetermined treatment plans are problematic because you know when the patient comes in, you need to have a patient-centered approach.

What does patient-centered mean? Patient centered means what’s best for the patient, not a one size fits all. You don’t want to have a patient come in with a hot low back and an acute sciatica and treat them the same way you would with someone who presents with science and symptoms as someone undergoing a dissecting aneurysm method that you can cause it, but they’re undergoing it.

It’s two different treatment plans. Triage is different. Everything is different. So it needs to be patient centered. And the thing we have to understand is a predetermined treatment plan is actually a good thing and it’s a bad thing. Listen, when you go to a dentist, the first thing they’re gonna do is they’re gonna do x-rays of your teeth.

They can’t see inside. Then they’re gonna take their probe and they’re gonna poke around. They’re gonna look, that’s all pre-determined. When you, if you’re having a stroke, you’re gonna go to the ER and they’re gonna give you tpa, which is a drug, which is a clock buster. It’s not even a question. It’s a predetermined treatment plan.

All these, every industry has their predetermined treatment plans, and we do also, and we’re only dealing with 24 movable bones, so that’s, we’ve got extremities, but the core of what we do is 24 movable bones. So it’s limited, and we do have certain things that are predetermined. However, there are things that need to be done that are not predetermined.

that make it patient-centered. And when you don’t do those things, you expose yourself to lawsuits. We’re gonna talk about that in a minute. Licensure issues, referrals, collections, because carriers need to see what you’re doing with the patient on every visit that is specific to that visit. That is patient-centered.

That is not just one size fits all. Now the carriers have taken this to the extreme in something they call a fraud for profit screen scheme. They actually named their campaign Fraud for Profit, and in that campaign, they’re hell bent on getting their money back threefold from you en Ricoh cases. So therefore, they’re hell bent on doing that.

And guess how many they’ve lost? Zero. None. None. Because let me rephrase that. Doctors say, oh, it’s nonsense. I’m gonna put in a motion to dismiss. And that’s a motion because the carrier’s allegation is nonsense. They’ve lost zero of those motions nationally, which means it’s costed doctors dearly, but they look at that.

Where they start is when they pay you and their algorithms kick in because they’re reading every single word in your report. There’s not a person reading line by line. It’s a computer and an optical character recognition program. They’re pulling words and phrases out, and they’re looking for commonalities.

And just like they say, if you hold a piece of paper up and you can see the same words 10 pages in a row that’s what the computers are looking for. and if you have that, they, you get flagged for a predetermined treatment plan and then it goes to s i u special investigating unit and then they’re off, then they’re off to the races, and they’re investigating you and that’s something you, listen, I’m married two days ago, was 47 years and I’ve learned a long time ago.

I don’t wanna win. Not only do I not wanna win the fight with my wife, cuz I’m gonna lose if I win. I just don’t wanna have it. It’s the same way with the carriers, okay? And it’s very expensive to have the fight win or lose. So you want to ensure that you’re doing what you know you need to do. So when you’re doing an e and m evaluation, and when you’re doing e and m, the purpose of e and m is management evaluation.

Look at those, that blue word management. , okay. It’s management. You need to manage your case. So when you’re evaluating them, you can have the same protocol for Amal Compression Jackson’s test, beter lass back, whatever you want to do. But make sure you do motor, make sure you do sensory, make sure you do range of motion.

Make sure you palpate, make sure you come up with a conclusive diagnosis. And here’s another hard mark rule for every area you touch. If you take away nothing else but this concept for every area you touch, you need a symptom, a clinical finding, and a diagnosis, non-negotiable symptom, clinical, a finding and a diagnosis for every area you touch.

And you can elicit that and perhaps we’ll have a whole nother segment on just the solicitation of symptoms. In areas where patients don’t verbally complain of pain in the E N M encounter, okay? And by the way, my eyes are gonna look sideways, I apologize, but I’m a nerd. I’m working on four screens, and even though I’m looking at you here, I’m looking at a screen off to the side.

I wanna make sure my point is in the right place. So in the E N M encounter, am I gonna order x-rays, MRIs, am I gonna do a chiropractic spinal adjustment, adjunctive therapies, or am I gonna consider collaborative care? All these things are the management component of what to do with your patient. That’s what makes it specific and not a one size fits all predetermined treatment plan.

Now, I had a conversation with one of my consulting clients this morning and he called me up and he said, I have a woman. She’s in her mid forties. She was in an accident. Here’s what she complained of. She was a diabetic. She has back pain. It’s not radiating down the leg, and I want to treat her and I just want to get a reality check.

I said, what’s wrong with her? She has back pain. I said no. I didn’t ask you what her symptoms were. What’s wrong with her? What tissue, what organ, what system, what’s not working, what’s damaged, what’s the problem? Because we all know there is no such thing as nonspecific back pain. That’s nonsense.

That’s dogma for those who don’t understand and we do. So I said, what’s wrong with this patient? He goes, , I don’t know. I don’t know what tissues. So what are you gonna do? I’m gonna adjust her. That’s absurd. What are you adjusting? The area of pain, what’s causing our pain? I don’t know. And here we are in circles again, so you’re gonna get lucky a whole lot of times and help that patient get better.

And then you’re gonna get lucky like the other doctor I’m dealing with in a malpractice case who’s gonna probably not only lose the case, but also possibly lose his license. And it’s interesting ChiroSecure. who is sponsoring this, who has no clue what I’m saying at any time will say, oh my goodness, mark, if they could do that, we won’t have claims against our doctors.

We’ll like that, but so will our doctors cuz they’ll sleep good at night. If you know what tissue or body part that your T treating, not just body part, but what structure has the pathology, okay, it’s game over. It’s easy. That’s the management component. Now, each and every one of you are trained. in your chiropractic training to determine what body part, and it’s easy when I walk into my orthopedic surgeon’s office, no matter what’s wrong with me, whether it’s my shoulder, my hip, my knee, my ankle, the first thing they do, an x-ray, they don’t even see you.

That’s their part of their normal examination. It’s a normal part of their examination because they want to see, it’s an ortho. They’re looking at joints. I had a hip replacement a year and a half ago. I walked into the ortho’s office. First thing he did, not him, his staff front desk, Dr.

Student, go right back to x-ray. The doctor will see you once. He has the x-ray. Took the x-ray, went in the x-ray was up. Here’s your problem. Your bone on bone done. That’s part of the treatment plan. Now, we all know, and we’ve done this before, that x-ray has zero side effect in a diagnostic scenario or a chiropractic office.

You need to have 56 lumbar x-rays in one session. It’s not cumulative. You need to have 100 thoracic x-rays in one session. It’s not cumulative and 5,000 cervical x-rays in one session. It’s not cumulative to have less than one in 100,000 adverse effective x-rays. So there aren’t any in our office. I can, I’m in the game 42 years.

I cannot think of any time that anyone’s taken more than 56 lu more x-rays in one session. That’s absurd to think about, but that’s the number. That’s the science. There’s science. It’s not dogma, it’s not rhetoric, it’s science. So I like X-ray, and here’s the answer. You want to know what?

Here’s what I said to the doctor this morning when you went to chiropractic college and these in practice. 33 years and I went 42 years ago, so I know they did that. Then when you in chiropractic college, did you mark X-rays where it was two times? P I E X A S I n Atlas left T seven Spinus. That is spinal biomechanical engineering.

You’re determining what’s going on in the spine. That’s how you know what’s wrong with your patient. So I said, if you X-rayed this patient and they had low back pain and they were two times px, two times P I E X with the body or the spinus or the Ma rotated to the right and L five, you will know exactly what’s wrong with your patient versus saying, I don’t know.

I don’t know. I don’t know. You do know. And then because there’s no radiation, you’ve been trained and I’m training the, I train all my doctors. There’s no radiculopathy, a myelopathic component, and you need to know what those words mean. Really understand what those words mean. But if there’s alopathic, a myelopathic component, then you order an immediate MRI and don’t touch your patient.

But in the absence of that, you order an MRI if the pain persists for four to six weeks. . The literature says six weeks, but I don’t like to go six weeks. If everything I’m doing isn’t working, it’s just too much. And if in fact I’m doing X-ray, digitizing and I have both. angular deviation and translation that are pathological.

And I’m not talking A O M S I for lawyers, which is an administrative de determination pathology. You have to understand pathology. These are all the things we teach our doctors. You need, the whole profession needs to understand that. But if there’s pathology in translation and angular deviation, I’m gonna do an MRI and do a stir view, S T I r, short tower inversion rating and recovery because I wanna suppress the fat to see if the ligament is pathological, and that’ll tell me more where the pain’s coming from and how to manage my case.

That’s a whole lot to unpack folks, but that’s the level you need to be at. If you want to have relationships with collaborative medical doctors, this is the level everybody works at. And by the way, when we train you, you get credits, you get AMA credits. Not only CE credits for chiropractic college through Cleveland University, but you get AMA category one P R A credits through State University of New York, of Buffalo, Jacob, school of Medicine, and Biomedical Sciences.

Why? , it has nothing to do with your license because it’s your reputation. And when you are working and communicating with collaborative physicians, especially neurosurgeons and orthosurgeon and pain management, doctors and neurologists, and you start talking about stir views and ligaments, when the fat is suppressed and you’re talking slight thicknesses, you know what they’re gonna say?

Where were you trained? And my answer is through the State University of New York, of Buffalo, Jacobs School of Medicine. Boom. instantly. You went from a lowly technician, probably that below of a physical therapist, that of a peer. You want to know where your referrals start. You just heard it.

That’s where your referrals start. All of this stuff matters because when I do my e and m and I’m managing I am triaging and you want to know what my triage is. My triage might be in my own office. I’m gonna be adjusting my patient heat stem, therapeutic exercise, neuromuscular reeducation, cold laser decompression, that’s triage.

After I have a diagnosis, a prognosis, then a treatment plan. And when I have all those three, then I treat, and here’s a mark Rule, a hard mark rule. If you don’t know, don’t touch. I know I can help this patient get well. I know that’s nonsense. One question. What body part tissue is damaged or mechanically pathological.

When you could tell me that you could touch your patient not until then, and that is non-negotiable. If you could tell me that, then you could touch your patient. And it’s a real hard rule and I’m very non-negotiable with a whole lot of things, and that’s one of them. . So you’ve also got a short assor to shield and your, the sword is the carrier’s, lawsuits, and the shield is your documentation.

So we want to ensure that we don’t have what we call predetermined treatment plans. We talked about this before. These are actual lawsuits against chiropractors all over the country. I have New York, New Jersey, Florida, Georgia, Michigan. I mean that Illinois that’s just up on, oh, this is New Jersey that’s just up on the screen.

And these are from mid to late 19 2022. I’ve got 2021. I’m sure it’ll be a 23 here shortly. I just haven’t pulled one in, but this is happening right now. And let’s face it. When’s the last time you heard? Of someone having a lawsuit against them. The answer is never. If you were sued, would you tell anybody?

Hell no. The only thing you would say, oh, I got 30 new patients last week, and you’re lying through your teeth. You’re not gonna tell anyone the bad stuff. I’m the one, everyone tells bad stuff to. I’m the one that they say, mark, where do I do? I’m in trouble. I got sued. What do I do? What do I do? I have one answer for everybody.

Hire a criminal defense lawyer cuz you need one. Chris, most likely you cut corners and corner cutters. Here’s a corner cutter. You ready? Are you doing height, white blood pressure, pulse? No. You’re a corner cutter. Are you doing full orthopedics for every region you’re gonna treat or are you doing motors sensory?

Dtrs. If you’re not doing those things, you’re corner cutters. You would never have gotten outta clinic as a chiropractic student without doing those things. Never ever be a corner cutter, because at the end of the day, you stand a much better chance of looking down the barrel of one of these, and they are not inexpensive.

So predetermined treatment plans, and this is predetermined treatment plans in our industry. When a patient comes in, they’re gonna get history, ortho, neuro motor. Dtrs and then what we’re gonna look at is possibly x-rays and then a treatment plan. But is it the same for every patient? I have no problem if it’s the same for every patient.

In the beginning, for every area you, you find a symptom, a clinical finding, and you diagnose, which I’m not getting into today. If you wanna adjust that patient, a patient in diversified or full spine diversified. The every patient, the beginning, I’m okay with that. However, with each reall or if you don’t do a reall and keep doing that visit after visit, then.

that’s not a patient-centered approach, but let’s read this. In the past, I’ve railed against carriers for accusing doctors unfairly of practicing in a predetermined manner with a one size fits all treatment plan. I’ve reviewed many lawsuits against doctors, and most are inflammatory from the ca carrier side, utilizing a fraud for profit scheme to get money back from the doctors.

However, in a few. The carriers are on point, as some doctors are lazy and were taught better in their chiropractic doctoral training. Currently, I’m in the midst of malpractice case where I’m the expert for the person who got hurt by the chiropractor. The DC was abundantly lazy and unprofessional in his approach to patient’s care and apparently lied in his records due to many contraindications.

Now, was I there while the doctor wrote after the fact? No, but I could tell you. When the doctor writes in his plan the patient was adjusted in three to four regions, and then the last pa the last sentence says, the patient only received physical therapy and no chiropractic adjustments in the same paragraph, one sentence that then all of a sudden, there’s an issue.

But never ever do that ever. Change your notes, your records. If you have to make an addendum, you can make the addendum, initial it, and date it. . If you have a lawsuit, never think you’re gonna sanitize your records. I guarantee you almost always it’s gonna work against you. If this doctor was just honest from beginning to end, it would’ve softened his blow.

But here are the carrier and my opinion about this type of work in which we are both aligned. Failing to legitimately evaluate patients to determine the true nature and extent of their injuries. Failing to arrive at legitimate treatment plans to address the patient’s true needs, reporting the same or similar findings for all patients to justify a predetermined, non individualized course of treatment, which is substantially immaterial, the same, almost every visit, regardless of the patient’s unique circumstances.

Let’s give you an example. You ready? On every visit? Every one. The only thing positive was Deerfield test. The doctor claimed he did cervical compression and be. on every single case. And by the way, right after December 8th, the patient went for an MRI and had a herniation so bad it was compressing his cord.

There is no possible way that cervical compression and Jackson’s was positive, didn’t do it. But look at this every single time. This is called predetermined palpation. Every time. But muscle spasticity, the same thing. Cervical, thoracic, lumbar, paradoxal rom boy, STRs every time the same thing. And here’s the other one on every visit, everyone this doctor listed, the patient had full range of motion exam, cervical, thoracic, and lumbar in every single visit.

Everyone 100% of the time, nothing changed. And the patient kept reporting, escalating pain, and the doctor said, it just went on and on. You need to have also, which will help you, patient-centered E M R macros. Okay? And they have to be patient-centered.

And that’s very important. I apologize for the noise in the background. I can’t cut that out. It appears my long guy is blowing the leaf blower around and I have no control. So I’ll talk louder, . But you need to have evidence-based macros on every sync for every pa, for every patient to pull from and what is it gonna be?

And it’s okay to have a macro that’s similar. But for each patient that has to change, visit by visit, you can’t do just this. And I’m sure this person clicked the same from their initial visit. I’m sure they did in their EMR system, and I’m not even sure they did this to the patient every single visit because the patient stated in deposition they didn’t.

But nonetheless, this is what you should not have. So listen folks.

This is easy. This is easy. If you want to do the same thing on every visit from the first reevaluation with most patients, I’m okay with that. On your first reevaluation, things should change to some degree, but each visit there needs to be an individual documented piece of what you did, of exactly what you did.

Please do not. Please do not do the same thing on every visit, especially if the patient’s symptoms change. If their clinical findings change. Just talk about what is, and don’t try to hide anything. Don’t change it. It’s easy. And you know what’s gonna happen if you do that? You’re gonna spend a few seconds more with each patient.

Seconds. You’re gonna get paid. You’re gonna get paid. So listen, if you wanna learn more about what we do I had a QR code up there on the consulting side. You can take a picture of that if you like academics that’s the QR code for that. Take a picture of this entire page with your cell phone.

If you want to call me, you’re more than welcome to do that. All of our academics are approved for c in every state, including AMA category one credits for medical credits through SUNY Buffalo Medical School. We talked about that. So listen. I hope you’ve got at least one nugget of information from today, and I just love sharing this stuff with you.

Thank you so much and have a wonderful day, and again, bye-bye. Thank you, ChiroSecure. Have a great day.