165- A Chat with Chiropractic Researcher Dr. Christine Goertz

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid and this week's episode is one for the ages. We have managed to get perhaps the most preeminent chiropractic researcher in history to come on this podcast. Dr. Christine Gertz and I discuss the past of chiropractic research, the future and what she's also working on right now. So this is an awesome episode. Before we get started, I'll say a few words about Rocktape. Rock Tape has revolutionized the soft tissue world again with new Rock Blades Mohawk. Featuring three tools in one surgical stainless steel hand polished tool and two attachments silicon sleeve and an ABS comb, Mohawk unlocks never before seen treatment protocols and you can find them for 175 bucks@rocktape.com Mohawk Additionally adjust your marketing is coming to Tampa June 7th through 9th. This is my first workshop deep dive Live Intensive. We are going to get stuff done if you are looking to step up your social media marketing in 2019. We're gonna go through all of the latest tips, tools, tactics, strategies and do it on the spot to make sure you go home with a great plan that is ready to implement and the content to do so. You can check that out@the evidencebasedchiropractor.com events. But without further ado, here is the conversation that I was fortunate to have with Dr. Christine Gertz.

It's going great Jeff. Thanks so much for including me today.

My pleasure. And I'm going to dive in right off the top and ask you right to the source what is the most exciting area of chiropractic research coming this year in 2019? What gets you excited when you think about it?

That's a really great question, Jeff. It has a little bit of a complicated answer. I always think as a scientist I'm living in sort of like a Christmas carol. You're living in the, you know, with science past, present and future. So looking you know, back on research that I think is going to have an impact that's already been conducted. I would mention a study that we had published last May in JAMA Network Open. I encourage people to take a look at this study. You can go and download it for free. JNO is an open access journal. You can find it on the you look at JAMA Network, just Google JAMA Network open and then search for my.

Name and you'll find that, find the study. But what we did is we allocated 750 patients to receive either usual medical care or usual medical care plus chiropractic at three military bases. And what we found is that those patients who received chiropractic care had a larger decrease in pain, an increase in physical function. They were more likely to report higher levels of patient satisfaction and reported benefit. And so I think being aware of the research that's already out there is important. Dr. Mike Schneider just published the paper in the same journal looking at lumbar spinal stenosis and conservative management for that, I think that's going to be another important paper that people should take a look at. And then there's research, you know, the research present. And so I have a grant with Palmer College of Chiropractic looking at dosing of chiropractic services in the va. And, and by dosing I mean how many visits? So we're going to be randomizing people to either receive around five or around 10 or 11 visits within a 10 week period of time. And then we're going to re randomize them to either be discharged to usual care or to receive one visit a month for the next 10 months. And I'm really excited about that. It's amazing to me that here it is, 2019. Chiropractic's been around for what, 125 years and we still don't really know how many times you have to get in the car and drive to a chiropractor's office in order to have a maximum benefit. And so I'm excited about that study for that reason. So that's what we're doing now is as far as the future goes, I'm putting together a grant application right now with Duke University, Dartmouth College and the University of Iowa and Palmer College of Chiropractic looking at building models of care that put either chiropractic or physical therapy at the forefront of the patient experience. So the idea would be a patient calls up to see their primary care physician, they've got low back pain and they're told by the scheduler, well, at this clinic we're trying either chiropractic or physical therapy first. And so building out those models, evaluating those models to look at outcomes. So I'm really excited again about what we've done in the past, what we're working on now, and what, what might be to come in the future.

I love it and I'm actually going to peel it back way before that. And I'd love to learn a little bit about how did you decide to become a chiropractor?

Well, I was. That's a good question. I was a pre med student at the University of Minnesota in the mid-80s and, and I was doing interviews with docs and as I thought about, as I was starting to think about applying to med school and in the mid-80s in Minnesota was right when managed care was just starting to hit. And I can tell you there were a lot of crabby medical doctors and they were feeling really squeezed by these new requirements they were unsure about, you know, at least some of the ones that I talked to about the future of medicine. And at about the same time I had a woman that was sitting next to me in my chemistry class and she was planning to go to chiropractic school and she talked a lot about chiropractic and how doctors of chiropractic treated the whole person. And I really liked that more hands on non drug approach. And, and so based on those two factors, I decided to visit Northwestern Health Sciences University. And I don't think I ever looked back. I just really resonated with their message.

And decided that that was really the direction I wanted to go in.

Now having said that, I almost dropped out of school at the beginning of my second trimester because I started to realize how little research had been conducted in chiropractic. And this is 30 years ago and the Mead study hadn't even been published yet. There was virtually, there was almost nothing. And so that really gave me pause and we were being taught in chiropractic school. Oh, if this is wrong, adjust C3 and if this is wrong, adjust L4. And once there really wasn't a lot of data behind that and, and discussing it with other doctors of chiropractic, some.

Who were the true pioneers in Chiropractic Research, Dr. Meeker, Dr. Triano. I started seeking those people out and I realized that there was a real opportunity to contribute something important to the chiropractic profession and to chiropractic patients by, by remaining committed to chiropractic, but really starting to look at things not only from the patient care perspective, which is so important. It's all about patient care. The only reason to do research is so that people are able to take better care of patients, but to go off more in that research direction. When I graduated from chiropractic school, I had a huge party and a whole.

Bunch of friends came I mean, I had balloons and a tent. And there was one friend in particular who was going to medical school, and he and his wife, my best friend Tammy, really helped a lot with the party. They did the graduation cake, et cetera. And a couple days after the graduation, he called me up and he said, well, what are you doing? How are you celebrating the fact that you finally graduated? And I said, I'm studying for the GRE. I enrolled in my PhD program the next, in my graduate program the next year and ultimately got my PhD in Health Services research, policy and Administration from the University of Minnesota.

It's so interesting because I think you bring up a great point about tying it back to the patient, the research. Right. And I frame it a lot in terms of the content is the research and getting it into the proper context, you know, is important for why it matters to those individuals that are going to make decisions, which are our friends, neighbors and community on a grassroots level. But I'd be interested to know from you, as you've gone through and evolved through the process of really becoming that eminent researcher, what have been some of the biggest challenges and obstacles for continued research, specifically within the chiropractic realm?

You know, that's a good question. I would say one of the challenges is that chiropractic in a lot of ways has been traditionally isolated from major university research intensive universities, as well as isolated clinically. And that's been a challenge from a research perspective. I remember my daughter one time, I overheard her when she was about five years old, one of her friends said, what is your mommy doing? And my daughter says, my mommy talks on the phone and goes to meetings. She was not too far off. And. But I always say that when I go into a meeting, I look around and if there are several women in the room, then I know I must be the only chiropractor. And if I'm the only woman in the room, then I know that I'm at a chiropractic meeting. And so I think that I'm frequently the only chiropractor that many of these folks have ever seen up close. And, and my experience has been that I impress them, but it's not because I'm so impressive, it's because their expectations are so low and so trying to educate people about chiropractic and what chiropractic has to offer has been a real challenge and engaging people to become involved in the research experience. And I will say that that has.

Changed a lot in the last 20, 25 years. I would say 25 years ago, if I wanted to work with someone on a chiropractic research project, I would basically go to them and say, if I do all the work and give you half the money, will you work on this project with me? And now the level of collaboration and interest in the research that I'm trying to do is really exciting, and it just gives you an opportunity to really develop even better research questions, looking at it from a multidisciplinary perspective than one chiropractic scientist would be able to do sitting in their office, trying to do it by themselves.

Yeah, that collaborative process is so important to be able to get things done at scale. And with the amount of papers that you've been involved in, if you were to look back and maybe pick out a favorite, whether it was due to the outcomes perhaps being surprising, maybe the challenges you encountered during the study and the ability to overcome them, what's maybe a paper that you look back and are especially proud of, either how it came out, the results, or it just holds a special place for you?

That's a really good question. I mean, there are so many examples that it's really hard for me to answer that question. I really can't answer that question. It's sort of like asking, which of your children do you prefer? But I will tell you, I do a list every year of 10 articles that I think every chiropractor should read. And I'd be happy to send you that list, if you wanted to send it to the people that are listening to this podcast to just get an idea. A lot of those. I'm a co author on a lot of those papers, but not all of them.

Yeah, I think that'd be a great resource. I'll make sure to get that out in the show notes. Absolutely. And kind of tying in with that. As somebody who's probably, in my opinion, correct me if I'm wrong, but brought more resources, also known as money, into chiropractic research than maybe anybody else in our history. What are a few of the key takeaways that you've learned throughout that process?

Well, that's a good question. I would say that I've learned that you have to collaborate. You have to bring multidisciplinary teams together in order to conduct the research. I think that that's really key. You have to make sure that you're asking questions that matter to funding sources. And so one of the questions that I got asked a lot when I was at Palmer was, why are you focusing so much on low back pain? And one of the reasons was because that is the number one reason that patients go to see doctors of chiropractic. And there are still a lot of really important questions that need to be answered.

But one reason was because that's what NIH was interested in funding. The DoD was interested in studies on back pain. And so you really have to focus on what, you know, where those dollars are. And you know, one of the things that I will say is disappointing to me is how little research funding comes from within the chiropractic profession. I want to start that out with a big shout out to NCMIC foundation who has just been terrific. I mean I wouldn't even be a scientist if it weren't for NCMIC Foundation. They, they gave me a postdoctoral fellowship when I was working on my PhD. That literally made the difference between my being able to go to school and not. They funded my thesis which was a randomized clinical trial looking at the impact of chiropractic treatment on lowering blood pressure. So my interest has always been towards some of those more, you know, some of those more, you know, disease oriented issues. But most people are interested in funding and funding low back pain research. I'd love to see the chiropractic profession if they want some of these questions answered, especially like for instance, pediatrics. We have so many gaps in what we know about, about chiropractic treatment of kids that need to be built and I think that money is going to have to come from within the profession rather than outside.

Yeah, that's a, that's a complex, it's a complex challenge and I'm sure that you've seen the inner workings of it firsthand probably more times than you can count. But it is, it is a difficult proposition. I remember in the orthopedic group that I was previously practicing with, I'd see email go out to the physicians and it'd be maybe for a lobbying, not research, but lobbying. Right. And people would say 5k, 10, 10k. But their salaries substantiated what they could do. And in chiropractic I think there's some challenge just based upon our current opportunities. But it's the ultimate catch 22 because the research is what's going to allow us to continue and explore new opportunities. Higher salaries, better breadth and depth of what we can do. But getting there is why I think your work is so, so important and tying into the, the long term tracking and really being able to substantiate things over time. I know a big focus of your work in the last few years has been with spine iq. And for any docs listening that are unfamiliar with spine iq, do you want to give a breakdown of what it is and maybe a couple of the important projects on your agenda with it?

Absolutely. So the Spine Institute for Quality or Spine IQ is a non profit organization that really what we're interested in looking at is how can we put, you know, high quality, evidence based, patient centered, conservative spine care at the forefront of the patient experience. Can we develop models of care where people were just automatically decide to see a doctor of chiropractic, maybe see a physical therapist, maybe see an acupuncturist. All of the treatments that are currently being recommended, for instance by the American College of Physicians guideline on low back pain.

How do we make that? How do we make that happen?

Taking a data driven approach. So we're Spine iq. Our mission is to define quality, demonstrate.

Value and build trust in conservative spine care delivery. And we have a number, we have been for the last. This will be the fourth year that we've had a clinical data registry that, well, doctors of chiropractic that any clinician is able to use in order to report to the CMS quality payment program, you know, what, better known as MIPS or macra. But in addition to that we're now offering some new products because I've learned over four years that it can be really, there are significant, can be significant challenges in participating in a clinical data registry. We're still working out how can we get data directly from your electronic health record into the registry so you're not having to do, you know, data entry twice. How can we. We're looking at ways to download the data from your EHR and upload it into the, into the, the registry. Our new registry vendor is Quality Value Health, which is also tied in with Infinity. So doctors of chiropractic that are already using Infinity to collect their claims data have already are mostly there because there's much less actual data entry that has to occur to participate in the registry. But nevertheless we've discovered that there are a lot of doctors with chiropractic who are just not ready to go down that registry road quite yet. And so we're also, we're going to be offering a new service where we collect patient satisfaction directly from the patient using what's known as the CAHPS Ambulatory Care Survey. And so this is a national standard for all ambulatory healthcare providers to use. And it looks at a number of domains of satisfaction. Basically, you know, how convenient was the care to the Patient, you know, what was their relationship with the doctor, with the staff, how well overall did they think that the doctor performed? And what we are doing then is we provide the doctors of chiropractic or well, I guess actually any clinician who's interested in using this service with quarterly reports that show how you are doing in each of those domains compared to everybody else in our database.

And then we're also starting a quality.

Recognition program for doctors of chiropractic. So there are basically five levels. There's level zero and then there's a bronze, a silver, a gold and a diamond level. And that allows doctors to really enter the quality arena at whatever level they feel most comfortable. So doctors at the bronze level we are identifying every chiropractor in the country who is either listed in Physician Compare, which that's connected to the cms, the Centers for Medicare and Medicaid, their quality payment program. So doctors who have participated and meaningful use and meaningful Use and what used to be called PQRs, they're listed on Physician Compare as being involved in processes that are identified with high quality patient care. So we're including those and then chiropractors who are listed in health grades who have a score of either four or five and have at least five raters. So that would be the bronze level. And we are doing that at no charge making that information available to patients. Patients will be able to search by zip code for these different for chiropractors and they'll be able to see what level the chiropractors have been are being recognized by spine IQ at. And then the gold level, there is a charge associated with that, a small charge of $159. And what we do then is we basically provide you with a mini webpage which has links to Physician Compare and health grades. But it also we verify that you have a license in good standing with fclb. We state that you've signed the Spine IQ quality pledge that you're you are committed to high quality evidence based patient centered care. We offer what we call quality school which will be bimonthly webinars that are focused on the latest literature, what the literature shows, where we're bringing authors of journal articles on with me to discuss the latest information, what you should know and allow doctors of chiropractic to ask questions questions along there. Then we're also listing the amount of, we're listing the chiropractic techniques that are used with hyperlinks from those techniques to what the evidence shows about those with a brief description. So Patients can picture it a little bit better in their mind and then getting a list of the different insurers that chiropractors have contracts with so that we can link to what the chiropractic payment policy is for each of those payers. So really it's a way for patients to get more information about you and your practice. And then the so that's the silver level. The gold level then is doing all of those things plus the patient satisfaction and which we'll also put on your mini website. And then the diamond level is all of those things plus participating in our clinical data registry.

I think that's just so fantastic and really just laying it out so practicing docs can do it in a systematic and an efficient fashion. And for everybody listening that's looking to get more information about these projects. What's the best place for them to go visit and to learn more.

So Jeff, the best place to find out more information about these programs is our website www.spineiq.org. you can also contact me personally at cgirtz c g o e r t z spineiq.org as well if you have more specific questions.

Awesome. I greatly appreciate all the work that you have done and I am really excited to see all the projects that come to fruition that are on your plate right now. I really appreciate you taking the time and hopefully I can twist your arm have you back on in a future episode.

Absolutely would love to do it. Thanks a lot to you and to all of your listeners. I really appreciate the opportunity to talk more about the research that I've been.

Involved in and to talk about Spine iq.

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