423- How Chiropractic Beliefs Affect Imaging Use

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. This week we are back with more brand new research. This just came out in chiropractic and manual therapies. It's all around diagnostic imaging, the use of it and how our beliefs and attitudes as chiropractors as providers might affect or influence our decision making. With diagnostic imaging we'll get into this and much more. A lot of interesting takeaways from this study that we'll highlight in just a few moments. I'll also of course drop a link down in the show notes if you would like to check it out. Before we get started, I want to say a few words about Patient Pilot by the Smart Chiropractor. If you are looking to consistently reach out to the hundreds if not thousands of people on your email list and I think you should, then Patient Pilot makes it super easy. We not only send automated content, that's awesome. It teaches and invites consistently. If you know what I'm about, you probably know what the content's going to be like. And with that there are two big buttons. Click to Schedule, Call to schedule so you can reach reach a majority, not like 1% or less of your audience. Like on social media we see docs reaching 50, 60% of their patient database each and every week. With great information certain subset of those patients reactivate by clicking Call to Schedule Click to schedule me. We make it super easy. If you'd like to learn more head over to the smart chiropractor.com but as I said at the top today we are talking research. The title of this study is the use of diagnostic imaging and the self reported clinical management of low back pain patients influenced by the attitudes and belief of chiropractors. This just came out this year and it is a survey specifically of docs in the Netherlands and Belgium. So this was a pretty interesting study. One it kicks off with something that I've seen alluded to but it was really great to see it just in plain text which is about half of the people that present to a chiropractor have the complaint of low back pain. So that's interesting. I always talk about on this show, hey, top three things that we see as chiropractors, Low back pain, neck pain and headache. Basically in that order. Now let's be clear, that doesn't limit our ability to only take care of those three things, obviously. But that is how most people begin begin their chiropractic journey. So this is stating the fact that actually 50 plus percent of them are low back pain related. So unless you absolutely don't want to take care of low back pain, and there probably is a small subset of chiropractors that don't want to take care of low back pain at any cost, if that's not you, you want to have low back pain information on your website, you want to be putting out content, you want to be having that conversation. Because if you're not diametrically opposed to taking low care, low back pain, literally half of your patient base presenting each and every year more than it is going to have it. So you want to connect those dots for those individuals. So this is where I love taking some of the pearls out of this study and really applying it far beyond what the study is about, but saying, okay, great, that's awesome data to know because now I know how to position myself in my community, whether that's with other healthcare providers, whether that's with the content I'm putting out, the videos that I'm shooting, and you need to meet your people where they're at. If you ask somebody to take three steps, missed conversion opportunity, you have to lead them one step at a time and meet them where they're at in their understanding. So by understanding that over half the people that see you are gonna have low back pain, unless you're diametrically opposed to it, it's a really good idea to put out a lot of information about low back pain so that you make it easier for people to say yes to you. Now let's dive into some of the guidelines. They highlight the fact that sometimes attitudes and beliefs can play really big roles in adherence or non adherence to clinical guidelines and recommendations. And they start out with a hypothesis that goes south. And that's interesting, that's actually a cool thing in this study. So they kind of highlight the fact that and there's oversimplifying, but I think there's a lot of truth to it. They say, hey, there's two camps of chiropractors here that we're talking about. One have an orientation towards a biomedical model, the others towards a biopsychosocial model. And they state in a biomedical model, the practitioner chiropractor in this study believes that pain derives from tissue damage, which whereas the biopsychosocial orientation, social and psychological factors are thought to influence pain as well. Now, I'll go into the sneaking suspicion that probably an overwhelming majority of people who are listening to this podcast are in the biopsychosocial camp. But it's an interesting way to look at it, and that's how they segmented out the audiences. Now, their hypothesis was that chiropractors with a higher biomedical orientation would be less likely to adhere to the imaging recommendations than those with the biopsychosocial model. Interesting hypothesis. We'll learn about what they discovered. So the aim of this study was really two things. One, to assess the attitudes and beliefs towards the management of low back pain with these docs in the Danish community in Netherlands. Secondarily, they were interested in investigating the association between those attitudes and beliefs and the adherence to the clinical recommendations of diagnostic imaging and the reported use of diagnostic imaging. So that's where they were coming at it. That's what they were hoping to accomplish and look at. And they found some really interesting things. So they had 203 people in this study, which was a return rate of the questionnaires of about 60%. The average age of the doc was 42 years old and about 40% were female, about 60% were male. So a couple things that they found as we dive into some of the stats and the data. They found that chiropractors in what they're calling the high biomedical class actually better adhered to diagnostic imaging compared to the two other groups, meaning a mid slant towards biomedical and a low slant towards biomedical, meaning more biopsychosocial. So this was really, really, really interesting. They also looked at low back pain guidelines on return to work, which were 80% adhered to the guidelines in the biomedical model, high biomedical, and only about 50% in the low biomedical model, which is the complete opposite of what they thought going in. The assumption was, well, in a biomedical model, if you think that the tissue is what's causing the pain and the tissue alone, you're probably going to take a picture of it to see what's going on, simplifying it down. And on the biopsychosocial model, maybe it'd be less likely to shoot the images. And they found the complete opposite. So that is interesting. Now, they also found chiropractors in the low biomedical model appeared to be least familiar with the practice guidelines. Only 52% were familiar. In the mid, about 30% of chiropractors were familiar and 11% in the high biomedical were familiar with the guidelines. So really, really interesting. Now let's take a look at what does it mean when we talk about Belgian and Dutch chiropractors? So this was interesting to me. There are 390 registered chiropractors in the Netherlands and 166 in the Belgian chiropractic union. So I guess I can look at that two ways. One is that's a lot more than zero, right? So that's fantastic. I also look at that and I'm like, oh, my gosh. And there's like, it was like probably 10,000 chiropractors just in the state of Florida where I live alone, and 50, 60, 70,000 licensees in the United States alone. So it's a relatively small but also a growing profession in those areas. Now, they did not, at least in this study, look at the schooling of those individuals or anything to that effect. So the questions start to become, okay, well, the guidelines are out there. How does adherence work? Right. Practically, Right? So guidelines get put out. And let me be super clear about where I'm going with this, and I'll try not to get off on too far of a tangent, but when we look at guidelines, there are guidelines, you know, left and right, recommending what we do. The guideline adherence in the medical world specifically related to low back pain, in my opinion, is embarrassing, terrible, and should be. They should be held accountable, quite frankly, when we still see, I'm talking mri, ct, advanced imaging, early, when we're seeing off label, use of steroid injections, when we're seeing, check the box, quote, unquote, oh, you met the criteria to have a laminotomy, a laminectomy, when we see the opioid crisis. These are stark indications that when I'm gonna talk about guideline adherence right here, and it takes a long time and all of these things, you know, shooting an X ray or not, in my opinion, is about the lowest. You know, should we all be professional? Yes. Should we all do what we believe is best based upon a few factors? Clinical guidelines, history of the patient, personal experience? Yes, all of those things. Obviously, technique plays a role with what we do as chiropractors. So all of those things play a role. So guidelines are not the end all, be all. They are a guideline, not a mandate for a reason, because they are supposed to influence the decision. So when we're talking about with chiropractors, let's say shooting X ray, that's about the lowest risk, harm type thing possible. And I look at the medical side, specifically related to neuromusculoskeletal care and specifically related to low back pain. And we're talking harms that are 100 to 100,000x that of an X ray, for example. Taking an opioid obviously has far greater harms and risk than profile than taking an X ray. But should we be cognizant of everything that we do as healthcare providers? Of course the Hippocratic oath starts with do no harm. So why is guideline progression so slow? This is shocking what I'm about to say. There's previous studies that Showcase it takes seven. It took 17 years for 80% of the profession to adhere to a new guideline. Not our profession with chiropractic. But this was a guideline based study previous, not this study. Specifically the fifth group, meaning the last 20% never adhered. So it was nearly. It was between. It was over 15 years for four out of five doctors to adhere to a new guideline and 20% of them just never bothered at all. That's a real problem. Now how do we address that problem? Probably conversation for a different day and a pretty complex conversation, but that is a real problem. When you're looking at 15 years plus for a majority of a profession to adhere to new guidelines and 20% never adopted at all. That's a real problem. One thing, there's a couple things that could be going on. One, the guideline might not be correct. That's possible is that the guideline just isn't applicable. That's a possibility, although most of the time not a probable type situation. The other components here are the fact that they're just not being informed appropriately. And then I'm going to say the third aspect is there's just no teeth on the backend to really be able to do the right thing in accordance with the guideline. Unless there are exceptions and with all guidelines there should be exceptions because human beings are dynamic and there is clinical experience and a whole host of items that play into it. So their conclusion here was quote, we distinguished three different classes of chiropractors primarily based on their orientation to the biomedical model. In contrast to our hypothesis, the high biomedical group demonstrated better overall adherence to the practice guidelines for the management of low back pain and diagnostic imaging. So a interesting study. It has been a long time since I looked at a study that they said hey, we got it totally wrong. It's the complete opposite based upon our hypothesis. So respect to the people who put this out to ship the study knowing that that was the case and kudos to putting out the information. To me, the big clinical pearls Here are 1. Guidelines take a long time to implement. And I think about this again, I always think about it through a marketing lens. I think about this and I say that is the opportunity when you're reaching out to other healthcare providers. Guidelines have showcased what they should be doing for their patients with low back pain for a long time. Most are not doing it. 20% probably never will. That's the bad news. The good news is that slow growth is every day of that is an opportunity for you to build a relationship, to open a door and to get in there and become that referral source. Second component is that we saw over 50% of these patients coming into every chiropractic practice every single year have low back pain. So the question becomes, are you putting out content that is appropriate to be meeting patients where they're at to make the decision easy for them so they don't go down the wrong road with the wrong expectations, with the wrong thoughts and beliefs about what will quote, unquote, fix their problem. So as the big take home messages, I'm going to drop the links, of course, down in the show notes before we wrap. If you have a pillow at home or you like to sell pillows in your practice, I recommend Align of Sleep. They support this podcast. I'm gonna recommend you support them. It's the pillow. It's an awesome pillow that we use in my house. So alignasleep.com, i'll drop that link down below. Awesome product sold directly to and through chiropractors and use it on your own. Have them in your practice. Great idea. Every chiropractor on planet earth has asked about pillows. The only question is, are you giving a direct and easy response that might produce a little profit for you as well. Second component is Shockwave Therapy has taken the world by storm. We use Stemwave in the practice that I own and they are willing to hook you up with all the bells and whistles. If you're interested, have a conversation. Go stemwave.com the evidencebasedchiropractor go stemwave.com the evidence basedchiropractor I hope you have a fantastic week in practice and I will talk to you soon.

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