How to Build Referral Relationships with Medical Doctors | Live from Fargo

I get that referral for the conservative care. Three weeks later, the patient, let's say, is not improving. And I'm going to refer to the specialist I call the primary care. 100% of the time this has happened. Primary care doctor. Hey, thanks for sending over patient John. I think he needs to see the neurologist. Do you want me to make that referral? Do you want me to send it back to you? I'll just send them over to the neurologist. They never want the patient back at that point. But it's the friction of the first referral and the unknown that you're trying to overcome. Thank you. So thank you for having me talking with Paul. It's probably. We're happy to travel new places and North Dakota would probably have been difficult to get to. I don't have any family here or anything like that. So I really appreciate the opportunity, Chris and the board for trusting me and having me come up and talk to you guys for the next couple hours. So I want to make it. And Jay did a great job yesterday. And I also want to make mine as interactive as possible. So if you're at liberty to answer questions and raise your hand, that would be awesome. That makes the. That makes things go a heck of a lot easier. As was said. This is a little bit of my background in history. I'll go through it quickly just to give you a little bit of context for everything that we're gonna talk about. I run a company called Evidence Based Chiropractor, Chiro Office Coverage Smart Chiropractor. But the middle two, the Total Spine Care Network and Orthopedic Total Wellness, are where we drive to today. And those were multidisciplinary or integrated clinic settings. One of them hospital based, and one of them was focused on outpatient surgery and ambulatory surgery centers. So it gave me a pretty unique insight into how the other side is doing things, so to speak, and where can we fit in? And that is really what started the journey of what became the evidence based chiropractor was seeing what was going on in the healthcare landscape at large and saying, okay, what can we learn from this as chiropractors and what can we bring back to our practices from a marketing sense to better it? Because that's something I think we're all certainly looking for. So we'll dive in. So who here is proud to be a chiropractor? Any. Any hand? All right, unanimous agreement. I love that. So the real question then becomes, are we happy with the current state of integration I would argue that, no, we aren't. I've found out this weekend that there's probably more integrated chiropractors in North Dakota, statistically speaking, on a percentage basis, than nearly anywhere else in the world, in my opinion. Which is awesome and definitely unique and interesting. But by and large, as Jay talked about and even Patrick the day before, we might be at 15% utilization. And that's probably really looking at things with a rosy cheeks, right? But we know as we'll talk about almost everybody in planet Earth is going to deal with some form of back pain. We are by far. And we'll dive into literature, the best first line treatment, and probably second line for that matter. But we need more market penetration, and that's hopefully where we're going to go today. So where do we start with this? I think one good place to start is a study that looked at exactly this, right, Referral patterns and attitudes of primary care physicians towards chiropractors. This was released about a decade ago. I think this is a great study because it kind of tells exactly what we want to see or exactly what we want to look at. Hey, what's going on? What are the attitudes? What are the differences? And what we find is very interesting. We find 95% of the population, roughly, is gonna deal with some sort of spine complaint at some point in their life. There's a lot of people, right? Hundreds of millions of people, billions of people across the planet. We also see that 90% of primary care physicians have been asked about chiropractic. Think about that. 90% of primary care physicians have been asked about chiropractic. That was startling to me. I didn't think that that would be the case. Now we see things drop off a cliff. We see 26%. What does that number represent? Well, 26% are the amount of primary care physicians that say, hey, I've made a referral to a chiropractor in passing. And in the context of the study, what they mean by that is they didn't discourage the patient from going to see a chiropractor, whoever that he or she may be. Right? So now we get to the truth of the matter, which is the 11%. The 11% is the amount that said, I've referred to Dr. Jeff, I've referred to Dr. John, Dr. Kelly. So there is a huge, huge gap between those. What do I call that? As you can see the title of the slide, to me, that is the gap of opportunity between 90% of primary cares being asked about chiropractic. Yet only 11% making a referral. That's a huge area where we can all make an impact in our communities by people understanding better what we do and by being better integrated into the care system. So I actually love this, and I bring this up a lot because it's true. If that 11% were 90% and it just went straight across, we'd be in a tough situation because what would you have to do at that point? Well, you'd either have to be a lot better than the next guy or gal, or a lot cheaper, you'd have to compete on price, or you'd have to be substantially better. And statistically, everybody falls to the middle. Right. So I'm sure everybody here is the best, including myself. But. But statistically, you'll fall the middle. So this is a huge opportunity and something all of us can take huge advantage of as we build and grow our practices or as they're in a mature state. So what were the four aspects of collaborative care that they defined as imperative or important? Right. Four things. Communication, defined, scope of practice, service delivery, and patient centered care. Is anybody against any of those things? All right, good. So that's an easy starting point, right? These are tenants that probably all of us utilize every day in our practice. They're tenants that all of us hold true, but we probably don't take action on them very often. And that's kind of what we'll go through in the second hour is really the action steps. The first hour will be setting that up with research. But keeping these things in mind is important as we start to dive through the research, because I always say it's, you know, it's content and context. Right? The content is the research, understanding what's out there or what's being published. But you have to put it into terms that matter. You have to be able to say, okay, how does this affect how I can take care of a patient? Or does it or does it not? And that's content, context. We'll be breaking down both as we go through. But let's take it back a little bit first. Anybody feel like this when they graduated chiropractic school? Just me. Everybody. Everybody else. Okay, good. So everybody usually is super pumped when they come out, right? You get out of school, you're super pumped. You're ready to take on the world. I felt the same way. And I especially felt this way in kind of my second iteration of my career. When I joined the first multidisciplinary group, I was super pumped. I was ready to go. I was ready to Hit the ground running. And lo and behold, what happened was my waiting room looked something like this. Does this ring a bell to anybody in the crowd? Anybody have a waiting room that looked like this at some point in their career? So I joined that first multidisciplinary group, Florida Orthopaedic Institute. I'm super pumped, and, yes, you could say I should have asked more questions before taking the job with this story. That is a fair statement to say. Right. But I'm super excited. They have infinite patience. I'm jazzed. I show up on day one. I'm like, okay, let's go. What's the book look like? And it literally is something to this effect. So what did I do? I said, what am I going to do about it? So, again, a lot of what we're going to break down today is personal experience with me because I went through the process of, Gosh, I'm super excited to go into this practice setting. There's nobody there. How do I get out there and bridge the gap? One of the things I started to do was to advertise my practice within their practice. And what I got immediately was a call to the principal's office, so to speak. They're like, man, hold on, cowboy. You can't just do whatever you want with our logo and go all crazy. So I became very, very limited in what I could do. And that's what drove me to say to myself, not in any genius moment, but just pragmatism. How can I talk to these other docs? Obviously, I'm have to generate patients from and through them. So how am I going to go about that? Because I didn't have any experience doing that, nor did many other people I knew at the time. So that's a little bit historical of how we'll break through this. So as we touched on a few moments ago, content and context, what is the research? What does it say? Does it support what we do? Where are their shortcomings? Where are we trying to learn what's emerging that's important? And then what's the plan? How do you utilize that information? How can you take that and either showcase it to patients or other providers, or in an ideal world, both. I think both are very, very important. So the good news is we are going over both today. Breaking down back pain. We'll start there. Who believes that chiropractic can do a lot more than just take care of back pain? Okay, I agree with that sentiment. We're going to start with back pain as the bottom of the pyramid? Because it's the easiest. We should have like 100% or 99%, maybe minus 1% on red flag, 99% of the market. So we're gonna start there as the baseline of what we'll talk about. So lifetime back pain, people are gonna have it, right? We've discussed that already. And point prevalence. Anybody know what that means? Point prevalence? So it'd be what's the amount of people at any given moment in time, right? So over the course of a lifetime, 90% of people in this room will have some sort of musculoskeletal or spine complaint. When we look at the 30% number, that tells us 30% of the people not in this room, probably. Cause everybody's super proactive about their health. But 30% of any given population has back pain at that moment. So that's all that means. So again, you start to think about the amount of people in your town, in your county, in your city, in your state. This starts to become really big numbers really, really quickly. A lot of people dealing with these issues. Why I like to think of it as a lot of it has to do with stuff like this, right? People could be proactive. I heard Dr. Jantempo and additionally Jay on Friday talk about being proactive, right? Everybody needs. Should be proactive with their health. But we see a lot of this. Does any. I have a next slide that ties us to a movie. Does anybody know the movie? This is like super bonus points if anybody can tie this to a movie. Any guesses? Any guesses? Yes. Nice. Yes. This is insanity, right? I mean, this was a movie that was like, it's hilarious and sad when they're showing it. It's sort of talking about sociology to a certain degree. Man, imagine if people got this far and then I looked on, like, I think it's probably Alibaba or something. And it exists already. It exists already. So this is a huge issue, right? People are not active enough. People are not proactive enough with their health. And this sort of thing is already happening, which is us leading us down that trail. And it costs a lot of money, right? Taking care of spine complaints, spine pain, spine issues. These are some of the most costly endeavors in health care. It is a huge, huge deal and will set the stage with kind of what other people are doing. So in 19, those are in the billions, if I have the zeros correctly. So anybody guess? Well, this is not a good guess, right? It has to be between 35 and 140, 1997. What are we looking at in terms of billions of dollars on spine or musculoskeletal. Any guesses? Are we bottoming it out or 72? 72. Let's see what we got here. A little bit less. But 2008, 10 years later, we are there and then some. And in 2020, we are expected to go to $140 billion plus. So with that being said, are we getting. Have we changed how we walk? I think we're still on two legs. Biped, upright. Right. What's going on? Are we drastically more unhealthy in 2008 than 1997? Okay, how about in 2020 than 2008? Maybe, maybe not. But you can clearly see the money is going up. Crazy, right? Substantially. That money is ticking up. Well, let's see if there's any correlation to anything else going on. Well, we know MDs have a tough spot. We'll get to that in a moment. MDs have a tough time with spine pain. Right. What are the three things that they typically will do or prescribe if a person goes into a medical doctor with back pain, what's the typical recommendation? There are three primary things. I'll classify all those as meds. Correct. So medication. One. Right. What's another one? Physical therapy. Two. What's three? Referral to another specialist. Right. They just dump it off to somebody else or an orthopedic or a neurologist, whatever the case may be. So this is great for when we start talking about action steps, because there's not a million choices. It's not like a Plinko board that you have to remember a bazillion things when you start talking to a physician, which makes it a heck of a lot easier. And that's something we all need to take advantage of. They're only doing one of three things every single time. They're either prescribing medication, they're referring to physical therapy, or they are upgrading to a specialist. Knowing that going in also is important, as we'll talk about later, because then you can start to proactively address it. Hey, what's your preference? Some of my other colleagues typically do this. Is that how you take care of these individuals now? You can have a proactive conversation that'll be kind of in the second hour. So NSAIDS is one of the things we talked about, right? Medication. NSAIDs are one of the big ones. So NSAIDs, well, if they're prescribed by the hundreds of billions, maybe trillions, they must be safe, right? Well, maybe not. Over 100,000 people each year are hospitalized due to NSAID use. 100,000 people due to NSAID use alone. That's shocking to me. It's absolutely crazy. 3,000 deaths annually. When's the last time you heard 3,000 deaths as a result of chiropractic adjustments annually? Forever, Never. It doesn't happen. But 3,000 people are dying each and every year due to NSAID use, which is considered the most safe? It's the, you know, no problem. Take these, get out the door, you'll be on your way. If they don't work, we'll upgrade the medication. That's completely crazy. Opioids. How many deaths per day in the United States due to opioid use? Anybody guess? Give you a hint. It's more than 0. 116. About 116 deaths every single day due to opioid use. What is one of the number one reasons people take opioids or begin taking opioids? Spine and musculoskeletal complaints, back pain, chronic back pain. These are directly linear. This is where I believe it's super important. And I don't say this to sound sensational. Everybody in this room saves lives. Really saves lives. Just look at the stats X amount of people taking opioids, hundred people dying per day and think about the fact of if you see that patient early on, not only does the research show their likelihood of taking opioids drops off a cliff, their lifestyle and quality of life benefit higher. These are big things. And think about just one person passing away, the ripple effect that has in their family, in their community. Everything else we're talking about multiple hundreds per week, which comes out to thousands upon thousands per year. So when you see a patient that comes in with uncomplicated, boring back pain in your practice, never take that for granted. Your opportunity to impact their life may literally save their life. And to me, that's also why it is so, so important that, that all of us take the onus is on us to get out there to the other medical, the other healthcare providers. Because on the flip side of that coin, every person that doesn't come into your practice is highly likely to be led down the other path. And that is a burden that all of us should bear. To say, I need to get out there. I need to be as proactive as possible. Because think about how many patients you'll see over the course of your career. A couple thousand, ten thousand, whatever it might be, that is a realistic. People within that demographic would have probably died if they wouldn't have come into your practice. Unless our health care landscape Changes dramatically over the next 10 years. And it's gonna change slowly. I got a sneaking suspicion, but it's very, very important. This is why I'm so passionate about this. So epidural steroid injections, another common thing, right? If somebody takes NSAIDS by their medical doctor, they get an mri. The MD gets the mri, they say, I knew it, there's a disc going on in there and it's closing down that foraminal canal. Why don't you go get an epidural steroid injection? 9 million ESIs are given every single year. 9 million. That was staggering to me. That sounds like a lot. I don't know, I don't know about you. That sounds like a lot to me. And what does that mean? That means over 25,000 each and every day divided by 365. Right? So 25,000 epidural steroid injections given each and every day. How effective are ESIs at relieving symptoms? Well, in the moment, you're dumping a whole bunch of medication on the area. They practically always work for a little bit, but if you don't do anything else, the person ends up in the same boat again and again. We've probably all seen the people. I had three shots last year. My doc said I can't have any more. We'll talk about why in a moment. You got a question? It's a good question. So the question is choosing the right type of pathology to utilize an esi, right? Is it a bulge, Is it a herniation, Is there a fragment? What's going on with the disc? And what's the best course? Realistically, they're just dumping a whole bunch of feel like. I mean, I always make the joke with patients I talk to. I'm like, quite frankly, I mean, they're sticking it in your spine, right into that epidural space because that's where you hurt the most, that's where the inflammation is. But quite frankly, they could stick it in your ass and you'd probably feel better. For a short amount of time. It's just a bunch of steroids, right? So yes, I think they could be more selective in terms of the patients that it's utilized on. For sure, because it's this blanket treatment because ultimately it's just feel, it's short lived, half life, feel good medication. Yes. There is research showcasing after post epidural steroid injection that those individuals who receive chiropractic care, manipulation, rehab exercises after the injection and fare a heck of a lot better than those who don't now, my question to be to this would be how many people are receiving 90% plus of the people who receive injections in their town as patients via referral after that injection? Probably not too many of us. Right? So that is a great point. Concurrent care is very, very important. In the event that somebody has that crazy hot disc, they can't move, they can't do anything. An epidural steroid injection. And let's say they have an mri. They make it through the MRI and we know that there's this crazy compression going on. That would be a person who might be a great candidate. Let's get you up and moving. We can't even get started with a chiropractic adjustment. Forget about rehab exercises until this thing calms down. You can either wait six weeks and it's going to calm down on its own, or if you have the injection, probably by the end of this week, we can start getting you up and moving. You are absolutely correct. And that is a very important nuance. Thank you. That's a very important point. So it does not always have to be this or that. It can be both. Right. I used to work with a surgeon that said, oh, man, now I'm going to. I'm going to lose the quote. It was like, you can have fleas and lice. It's like you can have both. It doesn't always have to be one or one or the other. So what are some of the challenges with epidural steroid injections? Well, this is one of them, I think. This is not Talked about ever. 21% increased risk of fracture with every ESI. This was by the Journal of Bone and Joint Surgery, not by Jeff's Journal. That's significant. Now think about how many people in your community have had 2, 3, 4, 5, a series of nine over the course of the last X amount of years. That's crazy. You're talking about this exponential risk of a compression fracture over time. I don't think that many people are talking about it, but it's also important I say this for all of us, for you, as you speak to a patient, understand what's going on with them. Ask good questions. If somebody comes in and says, man shots, I've had so many of them in my back I can't even count. You might still choose an aggressive, diversified move, but you might not. You might want to take a look. Great opportunity at X ray. The topic of the day, it seems in our profession might be a good idea to take a look and see what the bone Density looks like, especially if it's somebody who's aged. Yeah. Is there a time factor in. Great question. I don't know. This was not longitudinal, so I forget what the exact time frame on this was, but it was sort of like the first piece of research you're talking about, one that would be done hopefully soon to understand how does the past impact the present or future? I do not know the answer to that. That's a great question. It's something we should keep an eye out for. So what do we know from Columbia neurosurgery department? Well, ESIs are generally successful half the time. Newsflash, that's just about worse than placebo. Everything's generally effective half the time. I mean, that's absolutely crazy. Now, dumping medication on an area that's hot and inflamed will work, but you have to be in the right area. Some of the previous questions. You have to be in the right area. You have to identify the right pathology. You should have concurrent care going on. A lot of these things might not be done 100% every single time. So what do we end up with? We end up with generally successful, approximately 50% of people. I don't think that's good enough. Let's take a look at spinal fusions. 1990 to 2006, we went from 125,000 to 500,000. Now we approach 1 million spinal fusions per year in 2018. My question would be the same as earlier. Are we that much more unhealthier? Are we that much more unstable in our spine? To justify nearly a 10x over the course of just this last, what, 30 years? Seems a little crazy to me. It seems pretty aggressive. We talk about documentation and chiropractic a lot. We should all do the best job we can day in and day out documenting our cases. But sometimes I feel like, specifically with the documentation gurus, sometimes you can feel like, gosh, are we like the worst documenters on planet Earth? I'm getting paranoid just even trying to look back in my notes. Don't think that way. We see here 50% of the nearly half a million spinal fusions lacked adequate documentation. If there's anything I'd like to have adequate documentation on, it would be as if a spinal fusion was performed. I'd probably want to know why it was performed. Is it justified? Was it done correctly? Where are things placed? What's going on? Nearly 50% lacked adequate documentation. That's staggering to me. That is absolutely staggering. And this all plays in. This is the doom and gloom section, by the way, we're going to get to the nice section a little bit. But it's important to understand this landscape so that you can have educated conversations. And when I say educated conversations, all of this is not to say they're doing such a bad job. I don't believe that's the case. They have a limited tool set. They do the best they can with what they have. Many medical doctors, MDs, DOs surgeons, neurologists, interventionalists. But there are limitations there. And we need to also understand that because that helps give us the information and empowers us as a profession. International Society for Advancement of Spine SURGERY Increasing success and optimism may be leading some surgeons to overuse procedures beyond what the current evidence really supports. Well, duh. We just saw that they went from 100,000 to nearly a million fusions over the last 30 years done per year. Sounds a little aggressive to me. Right? And then we have the Medical Director of Spine Health. This is probably one of the most interesting slides that you'll read today. I'll read it as you do. Lumbar spine fusion surgery only works for specific indications and can only work if we can identify what this proper pain generator for the patient is probably 89% of the time, we can't identify it. To me, that sounds like not good odds. I am not a gambler, but that does not sound like good odds. 89% of the time we absolutely have to find out what this is to be able to make the right decision. And 80% of the time, 90% of the time, we can't. But we still go ahead anyway because we've seen those numbers. We didn't see that final fusions decline with this information over the last 30 years. We saw them exponentially increase. That means there's a lot of, no pun intended, being in North Dakota. A lot of cowboys out there, right? There's a lot of people doing their best. And let's give it a whirlwind. I believe there's a time to give it a whirl. I do not believe it's in the operating room. Call me crazy. Maybe I am unbelievably either conservative or progressive. I don't know. But at any rate, I don't want that to be me. I don't think you want it to be you. And that's where we need to have proactive conversations. I'll say this time and time again today for the benefit of the people in our community. Again, remember, I'm going to peel this back and I'm going To do this multiple times. A person in your community has neck pain, has back pain, they're 40 to 60 years old, they have radiculopathy. It's probably a disc, right? If they do not go in to see you, they will probably go in to see a nurse practitioner. They'll probably go in to see a. Do an md. What will happen? One of three things. Physical therapy, it might work. Active care is important. But if the biomechanics aren't good, that's where you see a lot of challenges, let's put it that way. But most likely they'll start with NSAIDs. Are NSAIDs going to work if they have a. I don't know, like, maybe sometimes, not really. You know, their body basically, you know, again, almost classic chiropractic, the NSAID might give their body the ability to heal themselves by just taking the pain away while they go through their normal movement. But it's not healing the pathology, obviously. So many people then complain again. They go back and say, NSAID stopped working. Well, NSAID just was cutting the pain until you became sensitized to it, right. Until your body adapted to it. So then they go back, get the mri. Lo and behold, MD says, I knew it. As if this was any. As if there was any question of this to begin with. I knew there was a disc that was pressing on that nerve. Let's get you over there for an injection. Well, we just talked about injections. And if the injection doesn't work or the patient has continued pain, what's happening? Well, they're having surgical intervention. Very likely. Right. And this is a lot of people, or maybe they got diverted down the path of, I don't want to have surgery. Well, we can give you some form of an opioid, and we already know how that's turning out. So this is very, very real. And this is happening every day, every single place, no exceptions. That is why we need to be very, very. I believe we should be so proactive about our communication so we all know the challenges. Additionally, once a spinal fusion takes place, sometimes they are the exact thing needed if you have major trauma, if you have abject instability, Spinal fusions can be a great thing. They've saved tons of people's lives, but you got to pay the piper one way or the other. Right? So we know adjacent segment disease takes hold as time goes on. Ten years, up to 50% in the cervical spine, 70% of people in the lumbar spine will have adjacent segment disease. About half of each of these will become symptomatic. So I don't want to overstate it. I'll be very clear about that. So about 25% of people who have a cervical fusion will have some sort of symptoms go on with an adjacent segment over the course of a decade. And about 35% of the people who have a lumbar spine fusion. So a lot of people get away without having issues. But we know you stabilize one area above and below, specifically above, takes the toll, Right. It's gotta compensate for that motion. And that ultimately takes a toll on the level over time. So annual expense per person for spine care. No surprise here. Right. We saw between the 1990s and 2020, this went up dramatically. People are spending way more money attempting to take care of their spine today than they were 20 or 30 years ago. So I thought it would be interesting. Hopefully this works. I thought it'd be interesting to lay two graphs on top of each other. The spinal fusion numbers that we looked at earlier and the expense per person have a very interesting correlative to them. Right. Spinal fusions are going up. They cost a lot of money. What are the other options out there? What else can we be doing? I would. I will ask you. Do you think. I think we're gonna have a slide on this. Do you think the expense is improving the results? All of that money spent, all of the hardware placed, all the medication used. Are we healthier today musculoskeletally, spinally, as a whole than we were in 1990? I'd say no. And the numbers would say no because we're spending a heck of a lot more money and a lot more stuff's being done. Right. So there are a lot of holes in the current state system. I pulled some things. Some of these are. You can see some of these are from one single day. So, like, May 7th. This a little while ago. A couple years ago. May 6th. May 6th. FDA warns of risks in cortisone injections to the spine. Medtronic pain out some huge settlement, and we have a. Anybody up for a leaky spinal device? Anybody? Any takers? Leaky spine devices? All right, me neither. So this is. But this is nuts. Like, you could pull any of this up any single time and start to see if you type in spine or anything like that into Google and look at the news, you'll see, like, crazy stuff come up, probably things that you don't hear about. And of course, we don't have these issues is what I'm getting at. We do not have these issues. Right. 100 deaths per day Due to our care. You know, if we had like two, we'd be like, you know, pulled in front of who knows who to say, gosh, this is completely unsafe. We'll talk about chiropractic safety later. But this is what's real and what's out there. I know I am going very deep and keep saying the same thing, but I want to emphasize the importance of it. If you do not get out and interject what you do early on to the people in your community and have more market share in a business sense, people are going to be led down a road which might result in not the results they or their family are looking for. And ultimately surgery is the end of the road. Right. So let's take a look at that ends the doom and gloom portion. Okay, so now we'll talk about chiropractic. We're going to take a look at some of the literature. I know Jay did a great job exploring this yesterday. I pulled some of my favorites that we'll talk about that tie in specifically to what we have reviewed so far. We are a very unique profession in many ways, but certainly in the area of research and what we do right, we have this really interesting combination that we are ultra safe, we have high effectiveness efficacy and we have high patient satisfaction. Anybody know another healthcare profession that has those three things going on? Not really. Not really. We have very. And I want to re say that again because again, I think this is important to really understand. We are one of the most safe healthcare options ever founded, seen, created, however you want to define that. Safe is good. But drinking water is pretty safe. But it might not work that well. Right. What's good? It's good for staying hydrated, maybe not good for taking care of aches and pains. Clearly at the level that we are. So we're effective also is my point. Right. We are not only safe, but we also have efficacy. That's hard to do sometimes when that happens, the patient suffers. Right. There might not be high satisfaction. It's safe, it's effective. But there are challenges in communication or challenges on buy in. This is like the, you know, the graph of you can only have two, not all three. We have all three. We are safe, we are highly effective and people like it when they get in. We only have that 15% market share. But time and time again we see the people that experience chiropractic are super satisfied with it. That just means we need to get out there to more people. So 8 to 12% utilization. What's any. What did. Did Jay mention Utilization. Where do we, where do we think we're at in terms of utilization? Is it 15% or 14? 14. 14%. 14% of people. Does everybody think that's low or high? I think it's low in North Dakota. You think it's lower in North Dakota? I think we're higher in North Dakota. What do you think? What would your guesstimate be? 30 to 40. 30 to 40%. Cool. Cool. Who practices in, I guess, show of hands. Who's in like what I'll call an urban area or a city for practice. Cool. Who's in? Super rural. Who's in it? It's me and 1,000 cows. Okay. Couple. All right. Just curious. So Cool. And who actually, and this is a good question as well, who here practices in an integrated or multi or interdisciplinary kind of way? Awesome. Yeah. Complete statistical anomaly. Who here practices solo by themselves, no associates, nobody else in their office. Cool. And who has associates or, and, or multiple practices might be some overlap with that. Cool. Right on. So utilization might be. Maybe you are correct. Maybe utilization is higher. I believe you. It might be 30 to 40%. All you have to do is double it. So you got a head start compared to the rest of the country. But at 30 to 40% you should be at 60 to 80. 90% of people are going to deal with a spinal musculoskeletal complaint. A majority of those people don't have red flags and many of them are going to seek care for it. Barring those red flags, almost all of them should be in your practice at some point in time, whether you're first line or whether they go and they have an injection. But now you're there for the follow up care. Very, very important. Who here does like active care and rehab in addition to adjusting in their practice? Cool. Who's adjustment only? Interesting. Okay, cool. All right. So this is a little bit old right now considering it's 2002, so it's starting to look a little dated. But I. Somebody presented this slide. I actually forget exactly who presented this slide, but it's a very, very important one. In this slide, I want this research paper to be redone and this slide to be updated so badly I might try to do it myself at some point in time because this tells the story of where we're going with chiropractic research. So bottom line is every other profession on planet earth would kill to show this slide. We get to show it. And I have a sneaking suspicion that it would be way better if it was redone today than it was in 2002. So prefacing it that way. So what am I saying with all this? So they took all of this stuff, right? All of these pathology conditions that people are dealing with and they looked at the literature and said, hey, what's out there regarding chiropractic, right? So positive obviously means that the study showed, hey, with these issues, chiropractic made a positive impact, right? Neutral or equivocal, we're not too sure. And it made a negative impact. People got dramatically worse. If you cannot see this, nobody got dramatically worse even on, for lack of a better way to say it, the weird stuff, right? So we start with low back pain and headache and all the easy stuff. And this starts to get kind of esoteric down towards the bottom, right? Things that we probably wouldn't scream from the rooftops that we treat day in and day out, many of us. But the bottom line is when they looked at the literature, even at worst, it's like, well, you're probably not going to hurt the person. There's almost no other profession on planet Earth that could have a slide with this amount of diversity in symptoms or pathology and have it overwhelmingly positive. Some maybe might help, might not help in literally dead zeroes across the board in terms of that seems like it's a potential harm. We already talked about medication. There's harms all over the place. NSAIDs, people with GI complaints. We'll talk about this later. People with GI complaints. You can't take NSAIDs if you've had heart conditions, you take heart medication, you can't take NSAIDs, right? We are so safe and effective. It's crazy. It's almost, it's astounding when you start to look at the literature. So important slide to keep in mind. I have kind of wrap up my thought on this. I have a sneaking suspicion. I mean, if we redid this now, this slide would be crazy. I mean, think about the amount of literature that's been produced since 2002 and today. I mean, it's gone up. It's gone up faster than spinal fusions have, let's put it that way. So it's crazy. So this would probably be 100 something. I mean, these numbers would be astronomical. And I haven't seen too many come through that would fall in the negative column. So let's take a look at some of these research papers. So safety of chiropractic manipulation on the cervical spine. This was done in 2007 by Spine Journal. Is anybody scared to see the result? Good. All right. So this was done by spine journal. I pull a lot of literature from spine, from the spine journal, because these guys have no stake in our game. This is a chiropractic journal. This is a surgical journal, by and large, that sometimes showcases other modalities. So if anybody's going to heavily scrutinize us, you'd expect it to come from a journal like this. It's a great journal, it's a respectable journal. But let's put it this way, chiropractic's not sponsoring it, right? So there's no stake in the game for us. So let's take a look at what they found. Adjustments given patients seen in serious adverse events. So what did they look at first? They looked at about 50,000 adjustments given during the course of this study. It's a lot. That's a lot of adjustments given how many people? About 20,000, I don't know, 15,000, 20,000 people somewhere around there. So everybody, when they looked at the course of people, everybody got a couple adjustments in this study. And it was pragmatic. In other words, it wasn't like you get two adjustments and then you're done. It was looking at the body of literature. 50,000 adjustments. Looking at data. 50,000 adjustments. 20,000 people. 15,000 people. How many serious adverse events do we expect? Zero is the answer. There were 0.50,000 adjustments, 20,000 people and absolutely zero serious adverse events. That's pretty staggering. That's pretty staggering. 2008, the European Spine Journal. Risk of stroke and chiropractic care. This has actually just been updated with a new paper that came out last month. Spoiler alert. There's no causation or correlation, but we'll look at the numbers just for giggles here. So let's take a look at a nine year study. This was done again. It was published in 2008. A nine year study. That's unbelievably long. Who here has not been in practice nine years? This is like longer than half the room has been in practice was this study. That's crazy. Nine years is a super long time to do a study. No evidence of excess risk of vba stroke associated with chiropractic care to primary care. That was reiterated with the new paper. There is absolutely no correlation or causation. If you go, if you look at a population of people and some of them go to the chiropractor, some of them go to their primary care doctor, it's the same exact rate of having a stroke, which means that there's no linear effect. The new paper also just talked about the biomechanics of it, which I think is important, and I'm not a biomechanical expert, there are probably people in this room that know more about this than me. But I'll describe in my words what the new updated research paper found. Basically what they said is where the vertebral arteries travel down, there's a certain amount of play. Right. And as we do an adjustment, where do we go with that adjustment? Into what's called the paraphysiological space. As defined as if I remember correctly. Right. You give an adjustment, you go range of motion and then you get into that paraphysiological space. Our bodies are designed to get into that space. There is slack in the vertebral artery to accommodate that motion. The updated paper basically said if chiropractic or active manual therapy or a cervical adjustment caused stroke, it would happen on nearly everybody. But the bottom line is you would have to get to failure point of the vertebral artery to cause that to happen. And by definition, that means every adjustment, if we were doing that, every adjustment would be injuring people because we would be breaking past that point. But going to the paraphysiological space or into end range of motion, or just a bit beyond, our bodies have a built in buffer zone of what's acceptable after that before failure. Therefore, it's a nearly impossible argument to say that it causes stroke. It doesn't happen. But the challenge that they bring up, which is the truth, is the chicken and egg, the people present with the symptoms that aren't identified by the chiro or the primary care, and then it's looked back on as that must have caused it when they presented with it going on in the first place. Because what are some of the signs or symptoms of somebody going through a stroke? Headache, neck pain, all the same stuff that we all see. Right? So this is why it becomes the chicken and the egg. But I would encourage you to look up that paper or you can shoot me an email afterward. Because what the updated paper did, they created a little algorithm that said if you see these things and then any of these two things, then you might want to grab a second opinion. So they actually finally broke it out to say if you see somebody with, you know, choose two of these, and then if they had two of those, and then three of these kind of things going on, which I'm doing a very bad job explaining right now. The gist of it is email me for it. Because they created a care algorithm to help that decision making process. Because taking a good history is the most important part. So let's take a look at this. Immediate changes in neck pain intensity and widespread pressure pain sensitivity in patients with chronic mechanical neck pain. Randomized control of thoracic man. This is a long title, right? So basically what does it say? People have neck pain and you adjust the thoracic spine. Does it help or does it not help? What do we think? Do we think adjusting a different region than the primary complaint is going to help optimists? I like that. And you are correct. So individuals who received thoracic thrust manipulation experienced significantly great reductions in neck pain as measured by the pain scale at one week follow up only. Does it hurt right there? It almost becomes so myopic to say if it hurts right there. I don't want to adjust any other regions. I don't do full spine. I'm absolutely evidence based and evidence informed. I just want to take a look at where it hurts and address that area. And I'm scared about billing or doing anything else because the bottom line is the research is on your side to take a look at the body. I always think about holistic motion. How is somebody moving their body? How is regional motion, how are they moving each region? And then segmental motion, how is each moving? And all play together because we walk up right under gravity. So my point in this is that if you're a doc who over time maybe has got. Not everybody necessarily needs every joint adjusted or every region adjusted every time, don't go the other way with it necessarily, but don't hesitate to look at the adjacent regions. Right. If we talk about extremities, you always look towards the next joint. Right. If you're adjusting a wrist, you'd look to, you know, vice versa. Don't hesitate to do the same thing in the spine. Take a peek, document appropriately, understand what's going on. And this is important as well. For let's say somebody that has, and we've seen, we've probably all seen these people, somebody that have multi level cervical, you know, spinal fusions and you might say, gosh, there's not much left I can do. Well, why do they have pain? Well, probably because they're fused top to tail. But don't hesitate to document and get in on the other areas. It can make a big difference. We walk upright, we have holistic motion, everything compensates. We have regional motion and segmental motion. So don't get trapped into. I think there's a prevailing kind of thing within chiropractic of people are getting really myopic on what they're doing in the name of specificity. We should all be specific and we should all be very earnest about what we're doing. But don't be myopic with it, is my point. Does that make sense? Cool. Most likely hypothesis for thrust manipulation to act is through stimulation of descending inhibitory mechanisms. This is where things start to get exciting. We'll look at some other papers. Central nervous system function, Right. Are we impacting the nervous system? What's going on when an adjustment is given? I'll hold off on that thought until we get to some interesting other research. What do we have going on here? I will paraphrase. This is the exact person we've been talking about all day. Patient has a disc pressing on a nerve and they are either going to get an adjustment or an injection. So they looked and said, okay, we know. And this was again, this is MRI confirmed, Right. So this isn't like, well, it might be a disc, it might not. This is person comes in with radiculopathy, we get an mri, there is a big chunk of a disc pressing right into a foraminal canal and they're lit up like a Christmas tree. Some people get an injection, some people get an adjustment. What do we think happens? Do both improve? Okay, Anybody think neither improves. Good. Who thinks that the injection will fare better? Who thinks that the adjustment will fare better? All right, let's take a look. A systematic review of the literature done the next year concluded that spinal manipulation is very safe and cost effective. All right, this is the teaser one. This doesn't tell the whole story, right? Okay, that's good. It adds to what we know. Let's get to the point. Both treatment groups had significant decreases. Both worked of pain scores at one month with a 60% reduction for spinal manipulation and 53% reduction for nerve root injection. The chiropractic adjustment. Spinal manipulation beat the nerve root injection when gone head to head. Not on every patient ever. All time. But in this study. And I want you to think about this because to me, this is very, very important. I'm going to keep repeating some of these things because I do believe they are important. This is a person with a disc pressing on a nerve in a foraminal canal. They had steroid dumped directly on that area. The steroid's job is to make it feel better and arguably to stimulate the healing process. That works pretty well. It's steroids. Yet what worked even better was no needles, no surgery, completely non invasive. The physical act of giving an adjustment. That is startling to me. It's absolutely startling at the power that everybody in this room has. And also it's a testament to the healing power that the person has all of us have inside our own bodies, right? The fact that a physical manipulation and adjustment can outperform literally just dumping a whole bunch of feel good medication on an area. That's astounding to me. And we've talked again about that patient in the journey of that patient. If they go down this path, and literally not in every patient of all time, I believe that concurrent care is best. But when we look at just the nuts and bolts of this, we are going to outperform an injection many times. So anybody do flexion distraction? Anybody in the house do flexion distraction? All right, cool. So a randomized clinical trial and subgroup analysis to compare flexion distraction with active exercise. So this is kind of. This is going to be unfair. This is kind of what I call the Chiropractic vs PT paper. Active exercise as a matter of physical therapy. I know they do more flexion distraction. Not every chiropractor does it. I know we do more. But this is just taking a look at those two things and saying, okay, well what happens? Right? Subjects randomly allocated to the flexion distraction group had significantly greater pain relief than those allocated to the exercise program. So people did better once they were able to get motion into the spine, not just strengthen from the get go. Anybody have ideas why or even in reference to the adjustment versus the nerve root injection that we talked about? Okay, so central nervous system changes, spinal cord changes. Like why does an adjustment work so well? I guess let's have that conversation. Spinal cord or ultimately how it's affecting the pathways, right? The pathways of the spinal cord are one reason. What are other reasons? Endorphin release. That's a good one. What else we got? Just mechanical facets moving, right? Facets are adhesions. What happens to the instantaneous axis of rotation as we age? As a very specific and really bizarre question. It moves posterior. So when we're young, it's like just about in the middle of the disc is where we initiate motion. Right. If you could pinpoint when you start moving, where does everything start from? It's like the dead center of the disc when we're young, as we age, that migrates posterior. So what happens? The facets become loaded as we age. Why do we see so much facet disease, facet arthrosis, facet challenge, degenerative changes, nasty bone spurs and all this stuff on facets because they're not built for it. They're built to do their job. But as we age, it's like you keep adding load onto them, you keep making them work overtime. They don't like it, so they become degenerative and arthritic. Getting those things moving is probably a good idea. What also happens to the disc as we age, it definitely degenerates, right? They become thinner. Typically, I will actually go the other direction on the blood supply. The blood supply to a disc inherently improves as we age because in the annular fibers, little capillaries grow in, and when that occurs, little nerves go with it and we become sensitized. When we are young, we can't feel our discs at all. And it's true, because we have basically no such thing as no and never and always, but we have very little nerve or blood supply to it. But as we age, the end plates grow in a little bit, and from the margins as well, let's say east to west, we do get some blood supply. And with that comes the nerve fibers. So as we experience challenges now we know about it, you might have had a challenge when you were younger, but you wouldn't have felt it or known about it. But we become very sensitive to it as we age. You combine that with the post, you know, the instantaneous axis rotation, migrating posterior and et cetera, et cetera, you start to come up with a challenge situation. So you think about what we do when we're able to get motion in, when we're able to affect the central nervous system, when we are able to get motion in the disc, motion in the facets. This starts to become why what we do is so compelling and so impactful. So randomized trial in spine adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain. I love this study because this is real, right? People go to see their medical doctor, then they might not be thrilled with the result. They kind of come see you, they're doing things. But people usually don't choose always one or the other. People choose both. So this is real world. If you add chiropractic to what they're doing in standard medical care, what's going to happen, what's going to go on? Right? This was in Spine in 2013. I absolutely love this chart. And you should too, because you can see here with standard medical care, how many people did much better, how. Not that many. How many people got a little, a little bit worse? Quite a few. If you added chiropractic, these completely flipped around. If you added chiropractic, look how many people got much better? Look how many people did a little worse. They literally, these charts do this kind of thing, something like this, you know, it's like they completely flip flop when you add chiropractic care. So what does that tell me? That means that what we're doing with chiropractic matters a little bit, let's put it that way. Right. That's a big difference. So there was a statistically and clinically significant benefit to those who received chiropractic. 73% of participants that had both had improvement or pain completely gone compared to 17% of medical care alone. So literally like the complete opposite, it completely changed the dynamic 100%. If somebody who is receiving standard medical care added chiropractic, that's a big deal. That is a big deal. And this is a great paper as well from the Spine Journal, the Cairo study, a randomized controlled trial on the effectiveness of medical and chiropractic management of people with acute mechanical low back pain. This was obviously, as you can see here, 2010 award winning paper. Anybody familiar with this paper? I will say I am happy that nearly no hands went up because go with me on this, this is an award winning paper that came out now nearly 10 years ago. Pretty big deal. An award winning in this spine journal is not a chiropractic journal, so to speak. It's an award winning paper talking to 100 chiropractors. Almost nobody in here knows about this. How the heck do you think the primary care doctors in your town know about it if we don't know about it ourselves? That's why it's important to learn about this. Because there is no way we can expect everybody else to know about it if we haven't been kept up on it ourselves. So important to know this kind of stuff. So usual care. So they defined usual care as physical therapy for low back pain. You know, usual care, narcotics, no big deal, just the usual normal day in practice. NSAIDs and reassurance. Hopefully you do better. That actually kind of works. Evidence based care they define. This is in 2010 they were already defining. Well evidence based care is when you include chiropractic. The usual is when you just do the drugs and hope for the best. This is almost 10 years ago. People were saying this in award winning papers, yet nobody knows about it. Absolutely crazy. So what did they find? The evidence based care group did significantly better at six months. So it wasn't just one week. Sometimes that's a question, right? Well chiropractic, you go in once you got to keep going back the rest of your life. It only works for a short amount of time. People were better six months. The results of the study demonstrated the equivalent groups of acute low back pain less than four weeks duration. Bottom line, greater improvement in the evidence based care group. And it's followed two previous studies commonly recommended by primary care physicians. What they're doing might be what they refer to as highly guideline discordant. This isn't an indictment of the primary care docs. If you're not there telling them what you do, they do not know they are going to become highly guidelined discordant. And as with anybody else in this room, highly resistant to change. It's like every human being ever, right? We get into habits, hard to change habits. So of course people are resistant to change, especially if they're not being told what is better, what is different, what is new and what do you do. So I hope I'm making a good case for all this here because it's important when we think about the people in our communities. We have spinal high velocity, low amplitude manipulation and acute non specific back pain. That sounds like an unbelievably generic super boring and crappy study, but I can assure you there is. Results are anything but. So let's take a look at what the results were. Anybody ever heard of Diclofenac? It's a very commonly prescribed medication for pain. So what did we see with this? I mean these results speak for themselves. People that took Diclofenac did not fare nearly as well. This is a pain score. People that had manipulation, their pain dropped down to near zero. And then we look here at the complete relief to deterioration. Zero deterioration for the individuals who had an adjustment or manipulation Diclofenac. This is like, you know, again, this looks like, I don't know, you could kind of just end up in any brat it doesn't like neither one's doing. But you could end up a little better. You're probably just as likely to have no change. You might get a little worse. Who the heck knows. Tying back to earlier, it was like, well, things work 50% of the time sometimes, you know, that kind of thing. Whereas this is a different story, right? That is a different, different story. So I hope this is all empowering. This was the first time spinal manipulation was investigated in a double blinded. This is very important, this slide, this paper. And while the title, again the title sounds kind of boring and crappy, this is a very important paper. This is the first time that spinal manipulation was investigated in an rct, a randomized control showing clear superiority compared to placebo and nsaid. This paper was done years ago and this is fine journal they're saying, yeah, it's clearly superior to nsaid. Clearly superior because how many people get this chiropractic placebo? We've all heard that. It's false. It's only false because we see the result of what we do. It's false in the literature, it's frankly not true. And there are high level papers that prove it. And we are, as you can see here, clear superiority to nsaid. That's a big deal. This is all tying into the same story. So high velocity manipulation can be recommended for therapy of acute nonspecific low back pain. Final evaluation, significantly better than NSAID and clinically superior. Clinical superior as they wrote it to placebo. This is a pretty good one as well. Does maintain spinal manipulation result in better long term outcome? The old maintenance care. Who got excited when I said maintenance care? Who got scared when I said maintenance care? All right, couple on each. So this is interesting, right, because people actually have looked at this and said, okay, with maintained care, is there any benefit? Is there any benefit? Let's take a look at what they found. Nonspecific low back pain represents 85% seen in primary care. 10% will go on to develop chronic disabling low back pain. We talked about that kind of story earlier, but let's dive in. This study confirms that previous reports showing that manipulation is an effective modality, especially for short term effects. All right, that's good. It's not super compelling. It's better than nothing. But they did find as patients did receive benefit, we believe that periodic patient visits permit proper evaluation, detection and early treatment of an emerging problem, thus preventing future episodes. Now that's interesting. That does not mean that every single company is going to pay you to do maintenance care. That is a different conversation and a different story. But rest assured, there is literature supporting the fact that it might be a good idea to get every adjusted every once in a while. Right? And this is showcasing it. Well, how? Why is it good? Well, it gives the opportunity for proper evaluation. When you go, you talk to the patient. Patient comes in every month, two weeks. There's no definition of the time frame in this. Say, hey, how's it going? How's your life going? What are you able to do? What are you not able to do? What quality of life issues are going on. You're able to detect an early treat. In other words, is there restriction? How is there mobility what's going on? These are good things to be proactive about. So if you were somebody who is fearful when I brought up maintenance care, don't be. Now that doesn't say that everybody needs to get an adjustment every single day for the rest of their lives. Three times a day, right? That's a different story. That's the other end of the spectrum. But don't hesitate to think about maintenance care if you haven't or have a conversation with your patient. There is benefit to it. There's significant benefit to it long term. So the costs are staggering. Patients are suffering. We must promote ourselves. This is what we've all been leading into, right? How do we take this body of literature, this body of knowledge, and start making it make sense for other people? Clearly, we're not going to go into somebody's practice and say, excuse me, sir or ma', am. Everything that you're doing and have done for the last 25 years is completely wrong. You have no idea what you're doing and you probably harmed untold people. That's not a good way to start a relationship. I'm just going to go off and I'm going to go out on a limb and say that. Right? So how do we take all of this information and make it so it is a conversation that's comfortable, that's natural, that actually helps people, because that's really what it's all about. That's what we'll take a look at. So historically, the lack of interdisciplinary communication has been one of our greatest challenges, right? That is the huge challenge that we're up against. So let's dive into five things. These are the five items we're gonna go into over the next hour. We're gonna talk about careful targeting. I'll explain what that means in a moment. We're gonna go step by step on how you can get out there yourself is where this is going, right? Speaking a common language, relevance and value, trust and rapport, and consistent follow up. If you take these things and put them into action, you'll be able to not only help your practice grow, in my opinion, but you'll be able to help a heck of a lot more people avoid that negative cascade that we saw earlier. So it's all about careful targeting. That's where we're starting. Careful targeting, what does that mean? Well, it means that if you're going to start reaching out to people in your community, you need to know who you're going to reach out to. Right? You need to know who you're going to reach out to. So building a target list, as I call it, is one way to do that. What do you think? Who would you put on your target list if you were going to make a list of other healthcare providers that you were going to reach out to, what might be some individuals that you put on, Types of providers you put on that list? Primary care, I heard. I agree. Emergency room maybe. Depending upon practice setting, that might be a great one. That's a good. That's a good one. What else? Obgyn. Is that what I heard? I agree with that. Depending upon practice type and style. Those are good thoughts. I agree with that. Let's dive in. Hopefully my next slide does. Yes. All right, perfect. So I recommend having a list of about 50 in some rural areas. That is impossible. I get it. But if you are in a more populated area, you can also condense this down. The bottom line is if you have one primary care doctor in your town, your list will be one primary care doctor. That's the facts. But in an ideal world, if you have 50 primary care doctors in your city, you don't want your list to be one. You're not going to catch any fish, right? You want to have your net big enough to catch some fish. So if you live in an urban area and you again start at the top and peel this down for yourself, I recommend a list of about 50. Find about 50 providers in that. What is the mix going to be? 50? Oh my gosh, that's a lot. Well, if you're in an urban area, it's not as hard as you think. I love 75% of your target list to be primary care internal medicine doctors. So regardless of Your list is 10 total or 50 or 5. A majority should be primary care internal medicine. Anybody have an idea on why 30% of their daily volume is related to spine and musculoskeletal care? Gotta catch the fish, right? So 30% of their daily volume primary care doctor is related to spine and musculoskeletal care. They are seeing these people already. 25% of your list should be subspecialty or specialty related. Meaning who are the ideal people that you like to see? If you like to see, Expecting moms have 25% of your list, midwife, doula, OB, GYN. If you're more sports oriented, 25% of your list, sports, med docs, orthopedic guys and gals. So that's where I think it's great opportunity to build a list in that way with careful targeting. So as you can See here. Here are some examples. Right. Depending upon your practice type, you build out the bottom 25% of your list with those types of providers who are your ideal patients. But keep the meat of your list primary care, because they are already seeing the people who should be in your practice. So that is where I get down with careful targeting. So how do we find these people? Again, some of us might have an easier time because there might just be one or two people on the way to and from your practice. But in the larger metropolitan areas it can be more difficult. Right. So how do you find these people? I recommend three ways to do so. You can go to WebMD and do a physician search by zip code and practice type. It will give you a list of all the providers of that type within your zip code. It's a really easy way to find and build a list quickly. Second is ZocDoc, basically the same thing. You can find a list of any type of provider based upon your zip code. But what's the best? Your own patients. Right. Your own patients are the best. Let me go to the next slide and see. Okay, cool. So who in here collects the primary care information on their new patients that come in? Cool. My goal is that 100% of the hands go up someday by the time I retire. So you should be doing it for every single patient. If you want to do any of this stuff. Right. I think you should anyway, but we'll talk about that. But how do you do it? Well, what I recommend is a two step approach. Let me take a step back on that. If you don't collect that information up front, you have negative equity that compounds. You can't send a case note. Where would you send it to? You have no idea who you're co managing with and you really can't communicate. You are blind to the information and the data. That's not a good place to be. Bottom line is ask your patients. So what do I mean by that? Have it on your intake form. When you collect this information, it empowers you. You can then send case notes as we'll talk about. You can have conversations. You can know who is popular with your patients. Now these are the people that you're co managing with more often than the others. Important to know. So have it as an option on your intake form. But the second step, that's going to get you 50% of the way there. Anybody that does collect it, you probably notice a lot of people leave it blank because they don't think you're going to do anything with it and quite frankly, probably everybody that raised their hand that does collect it, doesn't do anything with it. So the patient's right by leaving it blank. We're going to talk about that in a minute. But when it's blank, ask them if a patient leaves it blank. Hey John, I noticed you left this blank. We like to have that information to communicate and coordinate your care. You mind if I have that doc's name? It's that simple. It's not a sales process, not anything else. Just simply ask. That will get your collection rate way up there. What does this do? A couple things we already talked about. Ability to send case notes, you know who the other doctor is. You get to show off the proof of what you do. We're going to dive into all that. Number two, it gives you the opportunity to know who you're actively co managing with the most. These are other doctors you have the most in common with. Most patients, right? Patients at the heart of everything. And the third opportunity is anytime that that's left blank, you know it's because the patient told you at that point, I don't have one. What better opportunity is there for patient centered care than to say, hey, if and when you need to see a primary care physician, I'd recommend Dr. John or Dr. Kate. What does that do? Well, it does a couple different things. Number one is it prevents them from going to somebody who's going to tell them not to come in and see you. A little bit of defense there. It's a good way to practice. The other thing is you're obviously going to tell them somebody you have a good relationship with. Why would you let your patient just walk into anywhere to get care on somebody that not only might oppose what you do, but be doing something completely in contradiction to it? It makes no sense. So ask, find out. If the patient says, I don't have one, take the opportunity to be the best doctor and say, hey, I have a great relationship with X and Y. If and when you need one, I'd recommend Dr. Blank or Dr. Blank. It's the best way to practice. It's not only defensive, it's offensive and it's patient centered. It's the best of all worlds. So I'd highly encourage you to ask your patients who their primary care physician are and take that opportunity if and when it presents itself. So WebMD, this is kind of what it looks like. This is just an example of what it looks like. You can type in the specialty and the zip code or the address and it'll give you a list. So it's super, super easy to utilize, it's completely free and you'll be able to see all the different doctor types and who's around your area. So the bottom line is it's all about communication and case notes to me are the best way. Who sends case notes consistently? A lot of alliteration going on right now. Who sends case notes consistently to other providers to update them on the progress of the patient? Okay, we have one. I think we had one hand go up. Why not? Case notes are important because they do a couple things. Number one is they showcase that you exist, right? It's an opportunity to say, hey, I exist, right? That's a good thing. It's an opportunity also to showcase that you're co managing because when you send it out, it's obviously due to a patient, right? What's going on with the patient. The other thing is this, and this is the clincher, this is what kills me. You spend X amount of weeks, days, visits with a patient, it could amount to hours worth of time with the patient over the course of their care, right? You spend all of that time with the patient and you don't take three minutes to show off your results. A case note is a testimonial. That's B2B business to business, right? Probably everybody here talks or many people are accustomed to B2C testimonials. They're like, man, I'd like to have my patients go onto my website or Facebook or Google and say we did a Great job. That's B2C. They're talking to other prospective patients. You're missing out on the entire medical world by not saying, hey, I want to showcase to your other doctors that we do great work here. I spent all this time with you, you're doing so much better. Take that two to three minutes, we'll break it down and make it super simple and easy to get those out your door so it doesn't slow you down. But man, after spending so many hours with a patient, think about 90%. That's the other beauty of chiropractic. 85 to 95% of the people who walk in your front door are going to be super happy and a lot better when they finish care. So it's not like this 50, 50 thing. Like, man, I send case notes. I don't know if I want people to see my results. If you're a chiropractor, you get great results. There's hardly any chiropractors that get terrible results. So take the time to show it off. But what I'd encourage you to do is not this. Meaning some chiropractors I talk to, I'll say, do you send case notes? And they're like, yes, and it's 20 pages long. Do not do that. That is like, way overkill. Nobody cares. And I'll compare it to something the primary care doctor does not care about. The size, and you don't probably the size of the screw the surgeon uses in the surgery. The question is, did they do the surgery or not? The primary care doctor does not care about every orthopaedic. This is not the time to show off your knowledge. It's not like, well, the fifth time I did Kemp's test on the right side, I elicited one more VAS pain point. Nobody cares. Get down to the basics with your case notes. So what does that mean? Four things. This makes it easy, and we'll talk through it. Who is the patient? When did they come in? What are they dealing with, and what are you going to do about it? Also known in medical terms, patient name, data, service, diagnosis, treatment plan. Identify those four things, and you can make this super easy. EHRs make it arguably very easy or very difficult to spit this information out. So let's pretend that EHRs don't exist. What you can do is create a little template in a Microsoft Word or an Apple Pages document. At the top of that document, it has today's date. There's a little piece of code you can type into Google. How do I make today's date in a Microsoft Word document? A little piece of code where every time you open that document, today's date goes to the top automatically. You are 25% done with your case note already if you do it the day of service. Patient name. Type patient name and put it in red so you don't forget to not put it in Right. So put it in. Put patient name right. Yes. You need to type your patient's name in with this, so you're halfway there. So then what we have? Diagnosis and treatment plan. Most people in this room, it's 80, 20 rule. Probably you could look at your practice and say, well, 80% of people that come in have. I'll make it generic headache, neck pain, and low back pain. So take your top three or four diagnosis codes for each of those and type it in all of them. So it's longer. Right. Not everybody's gonna come in with all that stuff. But type it into your case note template. Underneath that, your treatment plan, you probably have a handful of ways you normally start patients out, there are exceptions, of course. We're talking about making things easy and streamlined. What do you do in treatment plan? You type your top two or three treatment plans. You save this document on your desktop. So now let's talk about patient comes in, end of the day, you're like, okay, John Smith came in, he was cool. He was what we normally see. His back hurt a little bit. Let me open up my note. You open up that template, you open up that file on your desktop. Today's date's populated. You type in John Smith. He came in with back pain, not anything else. You delete headache and neck pain and you delete the treatment plan that you did not do. It is way easier and quicker to delete stuff than it is to type it every single time. So make a template with your most common stuff and then open it up, type the patient name, and delete what doesn't apply. 80% of the time. You will have a case note done in less than 15 seconds. That makes it a heck of a lot easier to get out your front door right now. Let's talk about what's the benefit on it, the benefit on a case note, and let's talk pragmatic. So does that make sense as far as any question on making a case note? Cool? Be simple. The doctors care about who'd you see, when did you see them, what'd you find, and what are you gonna do? Don't complicate things. Patient name, data service, diagnosis, treatment plan. If somebody comes back and wants more information, you hook them in that net. Give them all the information they want, but don't kill everybody else and bum out everybody else by sending 20 pages to everybody. If somebody wants more information, they'll ask for it, give it to them at that point in time. You don't need to bum everybody else out in the process by sending a 30 page case note that nobody cares about. Keep it simple, keep it one page. Now, let's talk about how this actually works in practice. Right. Case note that you send out, and I saw this when I was in the orthopedic groups. You'll send a case note. Yes. If it's not an emergency, that primary care doctor is not going to look at it that day. I can nearly guarantee you that medical assistant picks it up off the fax machine or out of the email and puts it in the patient chart. Patient comes in, it could be next week, next month, or next year. The next time the patient's in that practice, the doctor is walking down the hall ready to see the patient. He or she looks through the chart. They're going to hopefully see your case note at that point in time. If your case note. Let's go back to the 30 page case note. If it's 30 pages in single space, that doc's like, forget this missed opportunity. If they're walking down and they see the case note could be from last week. Whenever the case may be, they're going to see hey John, saw Jeff last week for sciatica and read it that quickly. Open the door. Hey John, how's it going? You know the odds are in your favor being a chiropractor that John is going to say great, that's the win that you want right now. How often does that happen? I don't know. But I know if you send case notes on every patient, it's a lot more likely to happen than if you've never sent a case note in your life. Life. And for the 15 or 20 seconds it takes to build and send one in the thousands of patients that you could potentially see. I like those odds. Yes. So I guess my question is when is the best time? Anytime you bill a 99 something evals and reavals, 99201, 992-02-9921, 2214 do not. You do not need to send dailies. No dailies. Nobody cares that much. Update them when you are really doing your updates. Anytime you're so eval re eval discharge from active care. You don't get all three on every patient. Obviously. You know what I mean. Patients ebb and flow and kind of go in and out of care. But anytime you're doing that kind of thing and don't get crazy on visits like the medical doctors are used to sending for pt. If they see you're going to take care of the person for 12 or 24 visits, they're not going to freak out. That's usual and customary. So also, I mean you might choose to start with four or six visits. Don't get me wrong, I'm not trying to say that's a bad idea, but don't since you. It just made me think. Don't hesitate to get into a treatment plan with the person. So keep it simple. Like don't go crazy. Keep it simple. Somebody wants more information, they'll ask for it. Top secret chiropractic bonus tip grand rounds. Who has spoken or gone to a hospital? Grand round or spine conference? Couple people. Cool. So who has spoken at one? Who has gone to one? Who has gone to one. Let me ask that. And who has spoken at one. Cool Hospital grand rounds are a great opportunity to get out there to the people in your community. So what do I mean by that? Most large hospital systems have an affiliation with a university. That is where they might have their fellowships or whatever the case may be for the surgeons or the neurologists, et cetera. Most of them hold either a weekly or a monthly grand round. What does that mean? It means that there's a couple booths with spine device reps. The docs show up for an hour, somebody talks for 15 or 20 minutes. The docs get continuing medical education for that. And then they look at everybody holds it a little bit differently. And then they might look at cases together and just talk about it. Hey, I'm thinking about doing a surgery on this person. What do you guys think with the mri, et cetera? Almost all of this, incidentally, because they get medical education for it. They almost have to allow everybody in. It's like this weird thing where it's like it's not invitation only, but because the device reps are there, there's law obviously if there's a rep and how things are getting paid out and you have to abide by certain criteria. That criteria typically is that then you have to allow in other spine related health care providers. Now, you know, news alert. You probably won't get continuing education for it like they will, but it's a great opportunity to go and mix and mingle. So the way to go and do that is just to call up. If you have a local hospital system, just call up. Hey, this is Dr. Jeff. I just was curious if you guys have spine conference or grand rounds with your physicians at any point in time, it's highly likely that they were going to say yes. Or they might be like, we don't, but this other hospital chain 20 miles down the street does. It might be a good idea, it might not. Depends on the timing of things. But that might be a good idea to start showing up. Not only do you get to see who these doctors are, you get to learn about what their preferences are. And again, now you have empowerment going back to your patients on those individuals that might need a surgical intervention. It's a lot better to know the guy or the gal doing the surgery and whether you think they're absolutely off their rocker or whether they're super conservative. And it's better to know that by knowing them not know it by sending 50 patients and finding out on the back end about, oh, I guess that's what's going on or how this person does their business. So be proactive about it. A great way to do that is to go to grand, grand rounds or spine conference in a hospital based system. The other thing is leverage relationships. A lot of the benefit, in my opinion, of some of the smaller communities are, you know, reach out, see if you can get on tv, talk to people, be present, be approachable, be a health expert. There's no reason, especially if you're acting nearly in some of your communities as their primary care physician. Make sure that you're getting out to the newspaper and the tv. You should be their leading health expert. In that case, you should be featured in nearly every segment. So get out there. But you have to be proactive about it, right? You have to have a stance, you have to have some of this information and knowledge to be able to speak to it. Also, don't hesitate to get out and speak and become a member. As we saw last night, a lot of new members with the organization and association here in North Dakota. That's awesome. Be active, be engaged. That's important. And then reach out to some of the other physicians. It's a great opportunity if you can showcase and say, I'm gonna step to the side on this one a little bit. So I think this is a great way to promote a practice and I think it builds relationships better than anything. Bring, bring, bring. And people are busy. I get this. So you have to take some wins and some losses with what I'm going to say, right? But call up a primary care physician. Call up a surgeon and say, I'd love to sit down with you for a few minutes and even do a short interview so people can understand a little bit better about what you do. That's pretty compelling. Now, if you're in a town that has one surgeon and they don't need any extra business because they're getting everybody, all right, that might not be as compelling, but if there's a little bit of competition or you're in an area or a town or a city where there are multiple surgeons and they're running businesses called medical practices, you telling them, hey, I'm happy to expose you for free to my patient base, that's a great opportunity to get to know them, number one. But also to showcase. Hey. To your patients in your community, hey, I'm part of what's going on here. I'm not that weird person that has that weird practice that nobody knows about down the street. Right? It's an opportunity to become engaged with the Other healthcare providers. And to me, that's very, very important. And everybody has a platform to be able to do that. So take those opportunities would be my encouragement for you. And we'll skip that one. We'll go into the MD meeting. So when you're doing a meeting, like, if you're taking a meeting with somebody, don't get all weird and awkward with it. So don't get scared or anxious. We will work through what a good meeting is, like, some questions that you can ask and some ways you can go about finding common ground. So who here regularly meets with other healthcare providers in what I'll call the md? I don't care if it's an md, a DO, or anybody else who regularly meets with other healthcare providers? One, two people who is. Once every five years, you'll meet with another healthcare provider who's like, no way, man. Okay, so what's the reason why you haven't to date time? Who does not? Because time is of the essence, so to speak. I want to ask a loaded question. Who does not? Because they might be a little anxious or nervous to do so. Fair. Okay, good. When I talk about going through an MD meeting, I like to meet the other healthcare providers in my community. How do I do that and do it effectively and efficiently without feeling like I need to be a showman or feel like I need to sell my stuff. That's what sucks, right? Nobody wants to feel like, man, I don't want to go in and be, like, selling to somebody else. It's weird. It's kind of awkward. I'm not sure what to say. I don't want to go, like, hawk my goods and be like, would you like to buy something? Nobody really feels like they want to do that a lot. Right? So let's break down how you can have a conversation without doing that. I think it revolves around the Socratic method, so Socratic method, in my version of that, it means asking questions about them. Asking them questions. So we're starting to get a little bit more narrow here. Maybe like, well, that sounds great, but what questions? Right? There are three questions. When I go in and have a conversation with another healthcare provider, I am trying to get to three questions every single time. These are, by the way, these are not super complicated questions. These are not super complicated. Right? We're gonna go through them one by one. Are you currently seeing many patients with spine complaints? And I'm paraphrasing. You put this in your own words. Right? Are you seeing a lot of people with back pain? I don't know how you want to say it, Some variation of that we'll talk about. Why. What are you seeing more of? And what are your current treatment protocol? What's your current treatment protocol or protocols? So when I ask somebody and I go in and say, are you currently seeing a lot of people with back pain or people with spinal musculoskeletal complaints? Question number one, what do you think the typical answer would be? Well, I hope it's yes or else I'm probably in the wrong spot. Right, but that's why you ask. The question is, hey, are you currently seeing a lot of people with spinal musculoskeletal complaints? If the doc says to me, no, never. Good. Now I know I'm not in the right place. Or they might be a primary care, especially in more metropolitan area. A primary care. They say primary care, but you go there and they're like, no, we don't. We actually really focus on allergies and this kind of thing. Okay, I wouldn't have known that unless I came in here and asked you that question. Now, I know I'm not in the right place, but 95% of the time, the expectation is the answer is going to be yes. So it's a very easy question to ask first. Hey, thanks for having me in office. Looks great. Small talk for a minute or 2 or 10, depending upon who you are. Get to my question. Do you see a lot of people with spinal musculoskeletal complaints? My expectations are going to say yes. That's an easy first question to ask. And it leads into the second one very easily. Well, what do you see? Yeah, well, great. So do we. What are you seeing more of? All I'm trying to do is get them to paint a patient picture. What are they seeing more of? Oh, we're seeing a lot of people slipping and falling on ice. We're seeing a lot of people swinging golf clubs. I want to engage them with their practice. It also gives me an opportunity to understand, are maybe they seeing, I don't know, more migrant workers? Are they seeing more athletic people? Are they seeing general population? But now I'm starting to narrow down. I'm starting to narrow down, what are they doing in their practice? And also I'm starting to help them identify people that could be referred into my practice by asking them, hey, are you currently seeing any people with spinal musculoskeletal complaints? Yes. What are you seeing more of? Well, let me think about it. I don't care whether they say a little bit of everything. I don't care if they say, again, any individual, specific patient type. But I'm starting to narrow things down, and it makes it really easy to get into. Obviously, the most important question. What is your current treatment product? We see a little bit of everything. Great. So do we. What do you like to do for those people? If you ask those three questions, specifically the third one, you will have more information than 99% of the other people that have ever practiced in your town, because nobody's ever asked. And in my opinion, once you have that information, that is very empowering. If that doc likes to prescribe medication for every single patient that comes in, predominantly, I rather. Or do they prefer physical therapy or do they refer to another specialist? I'd like to know that, because now I'm not going in and being, like, tone deaf, right? I'm not going in and saying, you know what? Chiropractic is absolutely fantastic. You know, there's no connection there. But once you start to know, okay, are they seeing spine complaints? Are they seeing the patients I could see? Yes. What are they seeing more of? They're not going to surprise you. And what do they like to do for those individuals? Now you start to be able to piece together compelling rationales for why you might be a better option. But you have to understand what they want to do first, and that is absolutely imperative and something that I feel like is far underdone. Many people have never asked other doctors, what do you do for these people? And it's the most important question that you can ask. Yes. Ah, yeah. Yeah. You did not miss it. I did not say it. So good. But good question. I will answer it now. So the way that I would typically go about it would be to send what I call the icebreaker letter, which is a letter that says, basically, I'm very much paraphrasing it right now, but we have, like, a template. It introduces yourself. It says that you're going to reach out in a week or two with a phone call. So it preemptively states it and it tells a little bit about. Here are the things we commonly see and take care of with good success. It's not overwhelming. It's less than one page, but it creates a situation where then when you make the phone call, it's not cold. So I like to send the icebreaker letter that says, I'm gonna call in a week or two. And then I'll call in a week or two. And my call would be something to the effect of this. Bring, bring, bring. Hey, this is Jeff over at Langmeid Chiropractic, we've co managed quite a few patients with Dr. Jen but never had the opportunity to meet. Love to come over and learn more about your practice. Who can I speak to in order to set up that meeting? That phone call did not sound like this. Bring, bring, bring. Hey, this is Jeff over at Langmeid Chiropractic. You guys have a lot of patience. I don't really have enough and I'd love to come over and pitch you about every single thing you never wanted to know about chiropractic. Can I come over tomorrow? That doesn't work out very well so the scripting is distinctly the other way for a reason. Bring. Hey, this is Jeff over at Langmeid Chiropractic. We've co managed quite a few patients with Dr. Jen. Love to come over and learn more about your practice. Who can I speak to in order to set up that meeting? Three things if you've co managed with them, which by the way, if you're not collecting primary care information, you might never know. Getting back to why it's important to collect that information early on so you can be ethical when you call. If you've co managed, highlight co management. If you haven't, don't lie. Hey, we've heard, read or seen good things about your practice. I tell everybody that I work with, I'll tell you right now. If you can't look them up on Google Drive by their place. If their practice is in a dumpster on fire in a strip mall, you'd never go to. Do not put them on your target list or call them. Right. So if you can't say ethically, I've either read, seen or heard good things about your practice. Why the heck would you want to partner with them? So just be reasonable with it, but emphasize co management if you can. Number one. Number two is love to come over and learn more about your practice, AKA you're going to ask them some questions about what they're doing. People are a lot more compelled to say yes. In that case, not can I come over and pitch my stuff? And number three, somebody controls their scheduling book. So asking who do I speak to in order to set up that meeting forces them to make a decision. Oh, that's Deborah. She's not here today. Great. I'm typing Deborah down and next time I call back I just say can I talk to Deborah? Right. So it forces the conversation forward when you say who can I speak to? Or who do I speak to in order to set up that Meeting, it forces you to get to the person that's actually scheduling meetings. So that's the process that we've used many, many, many, many, many times. So this is why you have a list. Also some of the question might be, well, I don't know, how often is that going to work? One is better than zero and two is better than one. I don't know. But I know if you have a list of 50 and you do some of these things consistently, you'll get meetings and every one has the ability to impact dozens, if not hundreds of people. That's what this is all about. That's why I hammered that research so hard early on. One meeting, one relationship is worth the effort, not only from a return on investment perspective, but from a people perspective. Get out there and do it. So, current treatment protocols, we talked about this a little bit earlier. There are three things that you are going to get answered with every single time. Medication, physical therapy, or referral to another provider. Right. So actually let's role play this, this will be interesting. So, and anybody that's heard me talk about this, do not answer because you're gonna know the answer to this. So I'd love if this is the first time you've ever heard me speak or anything like that. This would be a good time to answer. If a doc said to you, well, we typically start with NSAIDs. And I hinted at this earlier, we typically start with NSAIDs. Okay. That's a legitimate thing. They're probably gonna say, what would your retort be? Or response to that? Any ideas? I like that. So you could. So the answer was you could talk a little bit about the effectiveness of chiropractic care. I agree with that. I will go a slightly different direction before I go there. This is take it or leave it. There's not one size fits all with this, by the way. So here would be the way that I would go about it. Doc says to me, we typically start with NSAIDs. I would probably say something to the effect of a lot of our referral partners start out the same way, but they get frustrated with people who have GI or heart complaints that can't take those NSAIDs. So they love to look towards our office to start those patients conservatively. What did I say? I said I'm gonna say it in a non medical way. I understand what you're doing. It's not my first rodeo. This must really piss you off and I can help you solve it. Right. So in a medical way, I said, hey, a lot of our referral partners Start out the same way. Well, that's interesting. This guy actually has referral partners. So you're preemptively loading things a little bit there. Right. But they get frustrated when. So hit a pain point. If it's NSAIDs, you got everything under the kitchen sink you can pick. I mean, there's a million things where you can't take NSAIDs. Pick one. But they get frustrated with patients that. Whatever. Insert contraindication here. And they love to look towards our office to start those patients conservatively. Or if you're a smaller community, you might say, and we've had a lot of success taking care of those patients. So if you felt like one other doctor and it's like, well, I know he's not referring to you. That doesn't sound right. You know, you always want to have integrity when you have the conversation. But there's a. That's an example of a way that you can go about it where you're not pitching or hawking chiropractic, but you understand where they're at. And they need to refer one person before they refer 100. Get that one person. If they understand the next time somebody comes in, oh, this person has that heart complaint. I was going to write this script. There's a moment of friction there in their decision making. The goal would be that they could think back to your conversation. Everybody means nobody. So get down. Drive down to that first specific patient. Then you send case notes. They start seeing results. We'll talk about putting it all together. What would be if they say physical therapy, let's say, move on to the next one. If a doc said to you, well, we usually start with physical therapy. This is a little tougher. Right? So how would you necessarily respond to that or what advantage would you be able to provide? A couple different ways you can go with this. And this is dependent, right? These aren't one size fits all. These are conversations for a reason and questions, not scripts. The same one doesn't work every time. So be creative with this stuff. But you might say something to the effect of somebody says, we love physical therapy, great. I do, too. We work very well with physical therapists, and I believe active care is a really important part of the treatment process. But what we find is establishing proper biomechanics first yields better results. But where people really love working with us is we're typically able to get patients over within 24 to 48 hours. And you don't need to do any authorization on your end. Saving time and money from a physician is a pretty Compelling argument. And I'm gonna break that down a little bit. It's not one size fits all. It doesn't apply to every patient. But I wanna break down what I mean by that. The benefit of the fact that there are a million insurance plans and it's like, well, what insurance do you have? Well, I have United Part 74z silver. You know, it's absolutely insane with the amount of supplements and plans, which is a good thing for us. Why is that? Because if a doctor is referring somebody to physical therapy, typically they're going to call to verify the benefits. That means they're paying their staff for services they're probably not going to render to verify the benefits before they make the referral. Nobody wants to pay their staff for stuff they're not going to get paid for. So that's a great opportunity and it's a real value add when they can come in to you. Because on a referral, a physician to physician referral, nobody's really going to do that. Just pragmatically. Now there's exceptions to this. If it's Medicare standard and they refer every Medicare standard to this physical therapy, they're not calling to verify the benefits. They know it. Right. It's not one size fits all. But with the splintered plans, there's an opportunity there. There's an opportunity to lighten the burden on them. Also, you could probably see a patient quicker. Many physical therapy clinics have three to four day waits to get people started. The longer there is between, the worse the outcome. So getting people in quicker is a benefit. It's a benefit that you do. The other thing is certainly I think it's important to touch on biomechanics. This is because it's my truth, this is why it's not one size fits all. I believe that yes, getting a joint moving is pretty important before you just start strengthening. That's why we do passive, passive, active, active care. And that's where I think some. My wife's physical therapist, so I feel like I can talk about physical therapy. You know, that's where some of the shortfalls are. If you just do strengthening from the first visit, which is the challenge with physical therapy. I know again, they do other things. There's a lot that can be done. But we've talked about and seen the benefits of getting in and giving an adjustment. There's a real benefit there. But you have to position it in a way that makes sense. Caveat time, that doctor owns a physical therapy clinic, you ain't getting the referrals. It's just his business, Right? If they own the physical therapy clinic. What I just said does not hold true. Every referral is going to that physical therapy clinic, and you're not getting any unless they're closing their physical therapy clinic. But what do you do in that case? I would argue that is your opportunity to say, great, we work really well with other therapists. I'd love to meet your lead pt. Then what do you do? You go to that phys. I don't recommend loading your list up with physical therapists. Remember, we talked about primary care doctors? But in the event that that physician owns a physical therapy clinic, good opportunity to go to the lead therapist. At that point. That is an and conversation, not an or. Hey, lead physical therapist. I'm Dr. Jeff, chiropractor in town. Wanted to introduce myself, let you know that we work really well. Dr. John said I should come down here and meet you. You ever have any questions, don't hesitate to reach out. Here's my card, my number. I'll also leave it at the front desk. Why am I doing that? Different in that way is because physical therapy appointments last one hour. People sit there all the time and complain. I was gonna say some other choice words. Complain about problems that they're experiencing. Right. They hang out at the front desk and talk about this. And usually with physical therapy, the opportunity that we have is people are scripted for one thing. The person is scripted from the physician because they have neck pain for 12 visits. And the physical therapy executes the game plan. The physical therapist executes the game plan. Well, is it ever a possibility that somebody that has neck pain has concurrent back pain? Yes, it happens all the time. But physical therapy treat regionally in sequential order. They don't treat globally. So this is a great opportunity. If they're going in for their neck and now complaining about their low back to the therapist. But the therapist knows you're not gonna steal their patient. You have an opportunity if you're in. Well, that. That therapist might say, you know what? Yeah, I mean, we're taking care of your neck. And the patient says, you ever heard of chiropractor? You think I should see a chiropractor for this? Let's be real. They're probably not gonna be like, you know what? Jeff came in last week. He's the best guy in the whole entire world. Let me walk you down to his office. What he's probably gonna say is, if you went in, he's gonna say, or she may say, yeah, I mean, somebody came in here last week they seemed all right. I think we got their card up front. That's a lot better than you never going there and nah, don't go see those people. This is cumulative as you get out and have these conversations and it can make a really big impact. So does that make sense? These questions make sense. Okay, and what about if they're referring. Let's go to the last one. Let's say the option was we're referring to, you know, what do you like to do for these people? Well, we refer them all to insert orthopedic guy, neurologist, whoever else, specialist here. What would be your potential retort for that? There's the co management aspect. So I'll give an example. I get, you know. Well, we usually refer all of our spine patients to insert specialists here. If it's true, hey, insert specialist here is great, but I know it can take weeks to get that initial appointment with them. So one thing we really pride ourselves on is the ability to get patients started conservatively and then we're happy to facilitate that referral back through your clinic if and when needed. Facilitate that referral back through your clinic if and when needed is important terminology because it basically encapsulates, I'm not going to steal your patient without saying I'm not going to steal your patient. It also encapsulates, you're still going to get credit, quote unquote. Now, pragmatically, I'll tell you how this has worked out. In my experience, I get that referral for the conservative care, three weeks later, the patient, let's say, is not improving and I'm going to refer to the specialist I call the primary care because I told them I'm going to facilitate it back through your office. 100% of the time this has happened. Primary care doctor. Hey, thanks for sending over patient John. I think he needs to see the neurologist. Do you want me to make that referral or do you want me to send them back to you? I just send them over to the neurologist. They never want the patient back at that point, but it's the friction of the first referral and the unknown that you're trying to overcome. Does that make sense by saying, I'll facilitate this back through your office, it reduces friction, it improves the comfort. And now they know that you are not a dead end if and when you have to make that call back to them to make the referral. I've never had a doctor that wanted the patient back just to make the referral, but you need to get one referral before you get 100. So you need to reduce the friction to that process. One way to do that, if they refer to other doctors, non chiropractors, specialists, is to say, and be truthful with it. Right. Make that call and ask. But I can nearly assure you every time they'll say, just send them on over downstream. So those are the three questions that I would certainly keep in mind. And now we talk about follow up. Right? So to me, I'm biased on this. Of course, one of the best ways to follow up is with research. Who believes that most medical. Well, let me phrase it a different way. Would the best thing to follow up with a health care provider every month be a discount coupon? We're all in agreement. I think so. That was near unanimous. So, yes. And it's just, again, it's just pragmatism. Like, what does that do for them? I don't know. It probably doesn't position you. Well, what do they care about? If coupons worked, I'd tell you to send coupons. But marketing, B2B marketing, speaking with. Communicating with physicians is different than consumers. Remember, we're talking all physician right now. So what is an easy way to be able to follow up? Because just having one conversation probably isn't going to turn the tide. Right. This is a system, a process. Well, one way to go about that is to follow up with research. So why do I think that's so important? Number one is because when I ask who knew about these research papers in this room, nobody raised their hand. So they don't know about it if you don't. So one is get the information out there just at a baseline level. The other is that to me, it positions your practice. You start to become somebody who's the educator in your community, even if it's passively. That's a good thing to be, in my opinion. The other thing that it does is it keeps you up to date on what's going on with the literature. If you're giving it out to somebody else, chances are you either bought it or you looked it up yourself, as we'll talk about, and you're able to then know more about it. That's a good position to be in for patients. So this all is cumulative. And I think one of the best ways to do that is through research. So this would be how I would suggest doing it. If you want, we'll talk about building your own. I like a format of a single page. If I'm giving anything to another provider. Why? Because they don't want again, if you send them a 20 page paper, you are punishing them. You're trying to be their friend, not their enemy. Right? Nobody wants to read it. That's why none of us read it. It's hard, it's confusing, they're long. Where do you get them from? All that kind of stuff. Stuff. Make it simple and easy. So what do I recommend for a format? Have your logo and name, right? You want to make sure they know who is sending it. Highlight a single paper, a couple quotes and talk about why it matters. What does it matter to them? What's interesting, what's unique. You don't need to be crazy. It doesn't need to be a dissertation. But say hey, here's something I found, here's why it's interesting and just make yourself a little template if you'd like to. And that gives you the availability to get out there and do it consistently. And research is one of the best ways to do it. It's also the most proactive way that you can reach out. Meaning this case notes will ebb and flow. You cannot control directly who walks in your front door, right? So you might not send a case note to somebody for a couple. You're just not co managing with them. So that's that. You're not going to be in their office every week having a meeting. You might be in every six months, every year, every two years, talking and chatting it up. So what happens in between? Because that's not marketing, right? That's communication. But that's not bridging the gap. Research does the middle ground, meaning it's a controllable asset of communication. You control if you get it out to them one time per month. So now there's consistency and drip, drip, drip. So kind of piecing many of these things together. Let's say they start to see a case note or two. I guess we're co managing with this person. Probably the results stink. They're a chiropractor, they see follow up notes come in. This person actually gets good results. That's interesting and unique. I didn't expect that. Now you're having a conversation with them, asking about their practice. Not hard selling them, but asking a couple questions, simple and easy that we went through. He or she seemed actually halfway decent. They're not crazy lunatics. That's interesting. And now in between that there's the drip of research. Further positioning your practice and staying top of mind. So as they're seeing patients, it gives the best opportunity for them to say why don't you go down and see Dr. Jeff? Nothing is 100%, nothing works every time. But very simple steps can get you in a lot better position, probably, especially as an independent provider, a lot better position than you are now. And it doesn't take a ton of effort to do, just needs to take the action to do it. So how do you go about building this kind of stuff? Pubmed in Google searches? Anybody look at pubmed since they graduated? All right, anybody have nightmares of pubmed since they graduated? All right, so pubmed is actually not a horrific place of destitute, which I initially thought it was. What you can do is very simple. You create a free account on PubMed. Basically you just say, here's my username, here's my password, here's my email. It's completely free to do. So then what can you do? You go in, you tell them what you want a search to be, meaning this. I'll give you a couple examples. Chiropractic keyword, spinal manipulation, second keyword, adjustment, third keyword. Then you tell them, do I want to be emailed every time this hits? Once a week, once a month, once a year. And they will automatically, magically, PubMed elves do all the work for you and they email you at whatever cadence you want. Once a week, once a year, once every time it hits any of the papers that have the keywords you'd like to be notified about for free. It doesn't give you access to the full paper necessarily, but it gets you started. This is a curated list delivered to your email box, updating you on the latest literature that's completely free. That's insane, by the way. And that's real. And you can do that right now if you want. So PubMed is a great place to go and look. Google searches is another way to do it. Google searches don't work as well because you'll get like every single chiropractic grand opening and all this kind of, you know, you'll get a lot of junk mixed in that. So I recommend just going to the source and going to PubMed. But I think the biggest thing to keep in mind is this is about positioning yourself in your practice if you're going to be in practice for 10. Most chiropractors don't go into practice to say, I can't wait to have two good years of practice. Maybe I'll get my contract extension to four and I'm riding out into the sunset. Most people are lifers, right? We're in this for our lifetime, so why not Take advantage of it and do everything you can to build the best practice you can. It doesn't mean high volume if you don't want it to be, but it means take the prestige that you've earned and that you deserve by becoming better known, by positioning yourself not only to the public, which most chiropractors do a good job. We rely on it for our life, right? I need patients to come in, I market to the consumers, I let people know I'm here. Don't forget about the other side of the coin. Don't forget about the other healthcare providers because as we've seen, marketing to consumers works. We've gotten 14% from zero. Right. 1894, there was no chiropractors, zero percent utilization. We're at 15. But I'm gonna make the argument that if we wanna get higher than that, we either need to have billions of dollars in consumer marketing. Good luck. Or every one of us needs to do a little work with the other healthcare providers in our community and you start nipping and two patients here and there and one or two amongst a lot of chiropractors makes a huge, huge difference. Not only in the business of chiropractic, but getting back to our initial patients lives. That is exceptionally important and cannot be understated. So as I said, you can make a difference. Your friends and neighbors are counting on you. But this is what it gets down to is action. People need to take action. It's not just this might sound good right now, this might not sound good right now, but the bottom line is regardless of what your thought is, you have to take action on this information and that is it. That action will dictate the result. Taking action will always dictate the result. I hope this has simplified and streamlined the process a bit for you. And with that, take what you will, right? There's no magic scripting, there's no magic numbers, but there is a process to make it a heck of a lot easier than shooting in the dark. And I guess to kind of wrap things up if you want to. I wrote a book about this. You can grab it for free if you visit that web address right there. And in the notes it might be wrong. So it's the evidencebasedchiropractor.com ANJC and you can pick up a free copy of the book which kind of outlines a really a step by step process. Utilize it, go for it, do your thing, go forth and serve. Thanks for having me, Chris. Thanks a ton. Hey, what's going on? If you loved that video, be sure to subscribe to this channel. The Evan Space Chiropractor puts out videos all the time at the intersection of marketing and research, showing you how to grow your practice while also growing your knowledge base. So if you liked it, be sure to comment down below or hit subscribe and I'll see you in the next video.