252- The Problems with Usual MD Care for Back Pain

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode we are breaking down what is usual care for low back pain. This is a systematic review of healthcare provided to patients with low back pain and family practice. This came out in Pain journal pain in 2019. Lots of gold nuggets in this study to help you understand what's going on in the healthcare landscape in your community, number one. Number two, that knowledge empowers you to be able to utilize that to your advantage by build more relationships, get more referrals into your practice. You have to understand what's going on to know where you can provide value. We're going to go through that and much more on today's episode. Before we get started, I want to announce the winner. We had a little contest for some posters that was asking you to leave ratings or review or feedback or however. It always comes out a little weird but leave feedback on this podcast on itunes. And the winner is Axon Health Channel chose at random. Axon Health if you are listening and you are Axon Health shoot me an email jeff the evidencebasedchirobrector.com and I will get you hooked up with the posters. Thank you to everyone who participated who hopped on over to the itunes page for this podcast and left feedback. Greatly appreciate it. It helps more and more docs find out. I think we're over 11 or 12,000 downloads each and every week which is incredible and extrapolate that out. It's like 2 million plus downloads over the course of 250 episodes. So thank you for tuning in. Never hesitate to leave feedback on itunes. It helps more and more docs find out about this podcast. Before we go any further. I'll also say the Smart Chiropractor open enrollment is closing down. So if you are looking to automate your marketing automate your marketing with email social screens. If you're paying for stuff to screen to stream across your screenshot, check out the Smart Chiropractor because we bundle that in. If you're paying for email service and no appointment reminders from your ehr do not count as actual email that generates business for your practice. Check out what we have going on and or if you are on Facebook, Instagram, YouTube or want to be then please check out the smartchiropractor.com but as I said at the top, today we are talking what is usual care for low back pain. This is a systematic review of healthcare provided to patients with LBP in family practice. And if you want to check out this study specifically, you can head on over to the show Notes. So last few years there's been a lot of action on this topic. Updated clinical practice guidelines from the American College of Physicians encouraged non pharmacological options, such as chiropractic, as first line treatment for patients with low back pain. That was a huge, huge, huge step in the right direction because that's the way it should be. And taking it back, I mean, a couple years ago I was like, well, maybe opioids shouldn't be used. Well, duh. But now to be peeled back and say, hey, before even NSAIDs, before any pharmacological options are offered, non pharmacological options should be explored such as chiropractic. That's a huge step in the right direction that cannot be overstated. So this systematic review assessed the care recommendations for patients with low back pain visiting primary care and emergency room departments between the year 2000 and 2019. So a lot of data, almost 20 years of data. And they discovered that many of the care recommendations were inconsistent with the latest evidence based clinical practice guidelines. Probably no surprise to you listening to this. So bottom line is so many of these primary care doctors, they are getting crunched from an insurance perspective. They're seeing diminishing reimbursement, they're seeing more patients because of that. They're just referral machines and you either are in their system or you're out of their system. And to be in their system is going to mean a crazy amount of referrals. And to be out of their system means you're never going to get one. But they're busy and they're challenged with reimbursement issues. So, you know, it's hard for them to remember a new treatment option or a new referral partner just because of everything that's going on. So then the question as we reverse engineer this is say how can you as a chiropractor make it as easy as possible for them and their staff to remember you to institute a referral to your practice? Those are really where consistency and follow up matter. So let's take a look at some of the stats and data from this study and we'll talk about some action steps as well. So the researchers found, quote, only approximately one in five patients visiting family practice were provided education Reassurance and advice regarding exercise, 20%, any sort of education, any sort of reassurance or any sort of advice regarding exercise. So that's a huge, huge failure that's going on now. If we drive one step back lower than that, we're gonna see. Well, no kidding. You know, when the primary care doctor is spending two minutes with a patient, they're not that much time to reassure. They don't have the systems, the tools or the education really to provide any sort of significant and specific advice regarding movement and exercise. And education, if it's not a pamphlet developed from a pharmaceutical company is probably out the window as well. So in one way, you look at it and you say it's an epic failure that only one in five are getting what they should be getting. And the other half of it, you look and say, gosh, I can't believe even one in five get that. But you know, we'll talk about the action steps in just a moment. Researchers also found, quote, the high quality estimates for family practice suggest around one in four patients are sent for lumbar imaging, about 20% recommended medication, 30 to 40, 35 to 40% NSAIDs, and up to 30% prescribed opioids. So let me read that one more time. High quality estimates for family practice suggest 1 in 4 patients are sent for imaging, 25% of patients are sent for lumbar imaging, about 20% are getting Tylenol, about 40% are getting prescribed NSAIDs, and 30% still, 30% still are being prescribed opioids. Absolutely nuts. And finally, the researchers found, quote, these findings indicate that evidence based advice was not routinely delivered to patients with low back pain in primary care. No kidding. So let's break down some of these stats, let's talk action steps and let's help you bridge the gap in your community. So step by step, we see one in four patients are sent for lumbar imaging. Now, in a primary care setting, that probably is too much. You know, again, I know that imaging has been a hot, hot button topic within chiropractic the last few years. You know, there's techniques that utilize imaging, there's techniques that don't utilize imaging, but in a primary care setting, there's no technique that the primary care doctor has that requires any imaging. So one in four patients being sent for lumbar imaging in the context of primary care definitely is a lot. And it's probably too much because the bottom line is, what is that doctor doing with that imaging? And the answer is, nine times out of ten, not very much. So that's one aspect of this. Now let's go to the second piece. 20% are prescribed Tylenol. Okay. I don't really have too much context regarding that. There's worse things to prescribe as we'll get to in a moment, but 20% being prescribed, like a Tylenol type type medication. Okay. But 40% being prescribed NSAIDs starts to get my attention pretty dramatically. You know, 40% of individuals with low back pain being prescribed NSAIDS on that. What could be the first visit with the primary care doctor is clearly outside of what any guidelines recommend and probably not in the best interest of the patient. Like, again, quite often what I see, just when you see it's really trickled out in the real world, patient goes in there. They may or may not have a structural issue, but. But definitely they have a structural issue. Is an NSAID really gonna do anything? Not really. And that's probably why we're seeing 30% being prescribed opioids, because they go back and say, oh, that medication, quote, unquote, didn't work. Well, of course it didn't work, because what was it going to do? So 30% being prescribed opioids is really too much. Right? It practically should be zero. It definitely should be less than 5%, probably less than 1%. So 30, 30% being prescribed opioids for low back pain in a primary care setting is quite frankly, inexcusable. When we see, let's say 100 million people go in because of a low back issue and 30 million of them are walking out with opioids, it's absolutely unacceptable. I don't care if there's 100 people walking into an office and 30 are walking out with opioids. This is what's going to devastate a community. And this is why we see in 2019, any gains in terms of the opioid reduction in opioids, war on opioids over the last few years, all of the gains that were made in 2016, 17 and 18, completely wiped out. There were more opioid related deaths in 2019. Many of them began with or ended in many cases, with prescribed opioids, not street opioids. And it's completely inexcusable. This is a 100% controllable phenomenon. And the onus has to be pushed onto these primary care doctors. I'm gonna say the AMA has to get involved, our public officials have to get involved. And us as people, as consumers, as health educators in our communities have to be involved. Because clearly the noise is, it's not getting through. When we see year after year after year after year of tens of thousands of deaths directly attributable to prescribed opioids for musculoskeletal issues, and the guidelines now recommend other things and nothing's being changed. Somebody needs to be held accountable at a certain point in time. There's absolutely no question of that. But that aside, let's talk about how you can make a positive impact in your community. And it's through really sharing information just like this with the other healthcare providers. So there's gonna be a spectrum of providers in your community, some who are looking for a chiropractor and just don't know one that's a minority. But I've seen it happen time and time again that you know somebody that they just don't know any chiropractors and they are willing to refer, then we have the middle that might not know hardly anything about chiropractic. They don't know whether they should or shouldn't be referring. They don't how to take action, and they don't know who to refer to or what really happens in a chiropractic practice. That's a majority of healthcare providers in the primary care setting. That's where outreach can make an impact for your practice. And then there's just that sliver as well, who will never. The third piece that will never refer. Okay, that's fine. You know, I'm not necessarily about taking a ton of time, energy and expense to change somebody's mind anytime you can. That's great. But I'm more interested in the middle, those individuals who just don't know which is a majority of providers, mind you, that just don't know that much about who we are and what we do as chiropractors. They see these patients coming in with low back pain and they order imaging because I think that might be the right thing to do. They prescribe an NSAID because that's what they've been trained to do. They prescribe opioids because either that's been what they've been trained to do, either there's pressure or they are lazy. But at this point, it's imperative. I'm gonna say it's two sides of this coin. Those docs need to be held accountable to make changes in their behavior. But you need to get out there and empower them to make those changes as easily, as seamlessly and as quickly as possible. And how do you do that? Well, three legs of the stool that we always talk about, you have to send Case notes to build trust. Case notes showcase that you co manage with them already. Critically important, you're not new, you've been co managing with many of these docs. If you see more than 10 patients in your practice ever, you've co managed with nine or 10 docs. So get out there and showcase the co management aspect. And the case notes also showcase the benefits patients are receiving in your practice. They are like reinforcements, like testimonials. Right? So get out there and get those case notes out there on your evals and reavals. Number two is the research. If you only have the case notes going on, you're probably going to struggle. Case notes don't flood anybody's office with referrals because we know that it could go a month or two. You're not gonna co manage with every single doc in your community every single week or month. So those gaps between case notes are killer from a relationship perspective. They will crush any progress. So research enables you to reach out each and every month, have your name, your logo, your information in front of them in a professional way. Drip, drip, drip. So the research is designed to keep you top of mind. And it is the marketing. It is the marketing. That's what we produce. Obviously we coach and train on this within the evidence based chiropractor, but the research is what we produce for our docs each and every month who are members with all their logo, all their information totally white labeled for their practice. So if you want to check that out, head out to the evidence basedchiropractor.com and then the third piece of it's meetings. Little more challenging right now with everything that's going on, obviously regarding Covid and Pandemic. But meetings are a way to accelerate the progress. Anytime that you can meet somebody, you can build trust and rapport at a faster rate and that enables you to reduce any friction, ask questions about their practice and get a better understanding on how you can make their life easier and serve their patients. So those are really the three legs of the stool. But the bottom line is what is the usual care for low back pain in a primary care and emergency room setting? The usual care is not very good. So get out there, bridge the gap, build some relationships, utilize this to also help guide your patients. I know we receive questions every single day from patients about my doctor said this, what do you think about this? Now you wanna stay within your scope as a chiropractor clearly, but being able to understand research like this, to know what's going on in their community and being able to guide and direct your patients and hope direct patients from other health who has your patients in their practice. Get out there, build those relationships with the primary care health professionals in your community and that's only going to benefit the people in your town. So make it a great week, have an awesome day and I will talk to you soon.

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