Why MD's Aren't Following Guidelines for Low Back Pain | Podcast Ep. 225

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid and we are back at the research. This week on the podcast, we're going to take a look at a brand new study published by Pain and it takes a look at primary care physicians and GPs and says, hey, are they following the clinical guidelines that have come out in the last few years for the care of low back pain in musculoskeletal issues? Some of what these researchers found may surprise you, some of it might not surprise you, but we're also gonna break down not only the findings themselves, but how you can utilize their findings to bridge the gap and build relationships with other healthcare providers in your community. So this is going to be a great episode. But as I said at the top, today on this podcast we're gonna talk about a paper published in Pain and it's titled what is Usual Care for Low Back Pain? Systematic Review of Healthcare Provided to Patients With Low Back Pain in Family Practice and Emergency Departments. So one thing that we've talked about a lot on this podcast over the past couple of years have been the updated clinical guidelines. The American College of Physicians, the American Pain Society and more have all come out and said, hey, you know, medications should not be first line defense. You know, conservative measures such as chiropractic care should be, but yet we still see a great divide between how that's implemented in practice. This paper took a look and said, let's look at the data, let's see what's out there. There's a systematic review. Let's see what the docs are actually doing. So what are they doing? Well, we're about to find out. These researchers basically estimate that around one in four patients with low back pain received a referral for imaging in family practice and one in three in emergency departments. Up to 30% of patients with low back pain were prescribed opioids in family practice and up to 60% in emergency departments. Large numbers of these patients that saw a physician for low back pain received care that is inconsistent with evidence based clinical practice guidelines. Wow. Lot to dive into. And that's just the first couple lines, right? So we seen this be a hotly debated issue within chiropractic over the past maybe year or so of imaging. Right? Should you take imaging? Should you not take imaging? You know, you might have a different philosophy on that depending upon what technique or practice style you have in your practice, but ultimately what they found is that 25, about 45%, basically of patients who are going into family Practice docs are getting imaging right off the bat and about 33% that are going into the ER and that is not in line with what their medical associations are informing them to do, which is only take imaging if there's a suspicion of a red flag. More alarming than that, dramatically more alarming for that matter, is that they found up to 30% of patients with low back pain were prescribed opioids in family practice and 60% in emergency departments. That is completely outrageous. Not only have opioids been basically not disallowed, but all organizations have said for chronic low back pain, opioids should never be prescribed. For acute low back pain, they essentially should never be prescribed and they should be relegated back towards advanced care post surgically or advanced care that's related to cancer. These medications just should not be being used at this point in time for anything resembling musculoskeletal care, especially point of contact, pre surgically or non surgically. There is no excuse for that whatsoever. We're gonna talk about what that means and also how you can position yourself. But the bottom line is people are still very guideline discordant. Now, why is low back pain an issue? Well, we've talked about this at length, right? Low back pain causes limitations in functional ability. It can impact mental health, which is a big deal. Depression, and it can result in financial hardship and reduces quality of life. Hey, with medical issues being the number one cause of bankruptcy in the United States, don't negate the financial hardship that low back pain can cause on an individual and on his or her family. That is a real deal. Now what they also found was you might be saying to yourself, well, emergency department, lot of people prescribing opioids, 60% are getting opioids. It's probably because many people going in there have really serious complaints. Well, that's not exactly what the research found. They're finding that in family practice and emergency departments, over 90% of individuals are presenting without suspicion of serious pathology, aka an infection, a fracture, cancer. 90 plus percent of individuals presenting, that's not a suspicion at all. Therefore, those individuals should not even be considered for these medications yet. They're still being prescribed at a pretty high rate. We'll dive into a couple more pieces of this paper before we dive into the actionable components of it. So they basically also found one of these other things in family practice setting. Two studies reported that 21 or 23% of patients received education or reassurance. What I mean, 20% of individuals are receiving any education they're basically receiving medications and or script for something else and sent out the door again, completely guideline discord. And one in five people are receiving any education about what's going on, reassurance that hey, you are going to get through this. Here are some action steps you can take. Here's some exercises, some at home care. None of this is being addressed. Now the beautiful part about this, as we'll talk about in a few moments, is this is a massive opportunity for you and I as proactive chiropractors to take advantage of that and step up and lead that conversation. Because we have the best communication, we have the best tool sets, all of that. But we have to be able to put it into action. We can't sit back and expect these people just to walk in our doors. We have to be able to get out there. So a couple other things that I'll point out, a couple quotes from this study is quote, only approximately one in five patients visiting family practice were provided education, reassurance or advice regarding exercise. These findings indicate that evidence based advice was not routinely delivered to patients with low back pain in a primary care setting. They also found, quote, the findings point to both overuse and underuse of medical services, including imaging, medication, prescription and provision of advice in the usual care of people with low back pain. And finally, they found around 35% and 50% of patients received NSAIDs in family practice and emergency department respectively. Rates of prescribing opioids were up to 30% in family practice as we talked about and up to 60% of patients received an opioid while in the emergency department. Only around 20% of patients received information and advice that aligns with clinical practice guideline recommendations. Therefore, they are basically saying you have a 1 in 5 chance. If you walk into a primary care physician office or an emergency department, you've got a one in five chance of getting evidence informed or evidence based clinical direction that's in line with the current clinical guidelines. That is really scary. When we look at 90% of people having an issue with a musculoskeletal complaint at some point in their life, we see chiropractic utilization hovering at a measly 10 to 15%. That is a ton of people that are going to be seeking care in a primary care office or an emergency department and only 20% of them, you have a statistic statistically highly unlikely you are going to receive recommendations that are in line with current guidelines or that quite frankly are beneficial for you. When I see a number that says 30% of individuals in family practice are being prescribed opioids 60%. If you walk in to an emergency department with a low back issue, you're likely to be prescribed an opioid medication. That's a serious issue. We have over 130 deaths each and every day due to those medications. Every single organization has stepped out in front medical, non medical, you name it, public health related and said this needs to stop and it needs to stop now. And this paper is brand new, just produced and we're still seeing that trend continue. So what does that mean for you and how can you put it in action in these last few minutes? Ultimately, to me this again reinforces the opportunity and the necessity for you to get out and bridge the gap with other healthcare providers in your community. If you are not taking an active role, then the public health of your community will suffer. You are the best option for spine and musculoskeletal care, bar none. We see that in the clinical guidelines time and time again. And the bottom line is emergency departments are there to evaluate emergencies, right? Infection, cancer, fracture. They are not equipped to have the tools or the care necessary to deliver to somebody if it's a non emergency situation. So getting out there, making friends with, building referral relationships with the doctors who work in those clinics is super important. They need to know where they can send those patients for that follow up care. They just have have a resource and you can be that resource. But you have to step out in front, create a system and a plan to reach out and then execute that plan day after day, week after week, month after month. It should be a routine part of your marketing and when it is, you can see crazy awesome results. We have docs within the evidence based chiropractor that are receiving 30 plus referrals from medical professionals each and every month. That's crazy if you think about just a thousand dollar average quote, unquote case value. If we want to talk business, that's an additional 30,000 dol per month into their practice. On top of that, most referred patients from medical providers are some of the most compliant patients. They're happy to be there, they follow your recommendations, they show up for care. These are some of the best types of patients that can come into your practice. It's not tracking down a lead, this is serving people who are reaching out and already have that no trust and like factor of you based upon the association from the referral itself. So get out there and bridge those gaps. On the family practice side, the primary care side, the same thing holds true. 30% of these individuals that walk into a primary care office being prescribed opioids is unacceptable. But the question is, what are you doing to change that in your community? And changing it in your community does revolve around getting out there and talking about it online through your social channels. But it also is about actually getting to those docs and building a relationship, offering an opportunity for them to refer the patients into your practice, letting them know that you can be somebody who they can trust. If they don't know trust or like you, you're not going to get those referrals. So how do you get that no trust and like factor? Well, the way we break it down within the evnus based chiropractor is case notes, research and meetings. We walk all of our docs every single step through every piece of that because we have found that that is ultimately the most successful way to go about it. If you want to learn more information about that, you can visit us at. Otherwise, I hope you are staying safe. I hope you're staying happy and healthy amid this kind of corona craziness as we've been going through in the podcast for the last few weeks. If there's anything I can do to help whatsoever, Please reach out jeffevidencebasedchiropractor.com Otherwise, keep an eye on our Facebook page, facebook.com the evidencebasedchiropractor and facebook.com themartchiropractor We've been talking a lot about telehealth, putting out a lot of tools. You've probably seen some emails come through. We've been building an entire system there that we're super proud of and docs have been getting fantastic results with. But overall, I hope you are safe, I hope you're happy, I hope you're healthy, and if there's any way I can help you or your practice during this time, do not hesitate to reach out to me. You are needed and the public is still going to be looking for you. I have a feeling right now people are suffering from musculoskeletal issues at a higher rate than usual, not less. Telehealth is one way to bridge that gap, but not to pull this podcast a completely different direction. I want to focus really on the family care in the emergency room. That's an opportunity for you to bridge the gap. You need to do it for the health of your community, for the health of your practice, and ultimately because it's the right and best thing to do. Have a great week and I'll talk to you soon.

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