#56 - Medical Collaboration for the Private Practice DC with Dr. Alex Frantzis, Part 2

FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to consume. to digest with actionable information that you can implement into practice right away. Let's get started. I'm your host, Jessica Riddle. Welcome and thank you for listening. Today, we wrap up our 2-part training on medical collaboration for the private practice chiropractor with Dr. Alex Francis. In part 1, we got to know the medical model and how medical referrals work. We discussed best practices in approaching medical providers for co-management of cases and chatted about the importance of addressing mental health as a component of chronic pain and pain management. In today's episode, we discuss the easiest way to effectively communicate with medical providers and the best tools to build professional relationships with multiple providers in your local area. And who better to speak on this topic than Dr. Alex Francis? A board-certified chiropractic orthopedist who owns several integrated health centers throughout Northeast Ohio. A 2008 graduate of Logan University, Dr. Francis began his first multidisciplinary clinic soon after graduation, growing to 3 locations and employing a team of providers including a board-certified orthopedic surgeon, general practice medical doctor, physician's assistants, physical therapists, and massage therapists. In 2013, he became staff privileged with a local hospital in Cleveland and has operated an established office in the hospital since 2017, working with specialty teams such as primary care, general surgery, vascular surgery, and podiatry. Most recently, Dr. Francis has expanded to integration with an urgent care facility, offering chiropractic care as part of their model, managing neuromusculoskeletal conditions alongside various other healthcare specialists. This 2-part training is going to provide you actionable steps that you can take to begin establishing relationships with medical providers in your area. It will also give some guidelines and best practices for overcoming misconceptions on what it is that you do, and of course, establishing yourself as a trusted partner on your patient's healthcare team. Let's get started.

So that's kind of it. So let's talk about co-managing care. This is a good topic that I always talk to students about, and I know we got a few students here. I'm hoping more students watch it. Co-managing care. God, I don't know how many times I see it where I talk to different providers. I talk to my orthopedic surgeons or I talk to my primary care, and they tell me the story about how they sent something to a chiro for low back pain. And the chiro ended up telling the patient, don't take your diabetic medication. You can treat your hypertension off your meds. Just do these exercises and get fit and all this stuff. And it's so aggravating to me. It's so, I mean, I want, it almost keeps me up at night when I hear these stories from providers, from, we get referrals, chiro's getting referrals from these primary cares, from these orthopedic surgeons, and they're going off some tangent and treating something that they really shouldn't be treating. So never attempt to treat something outside of neuromuscular, NMSK. Now we are trained Knowing GI/GU stuff. We're trained knowing cardiac stuff and lung stuff. And yes, we are trained in that, but by no means are we specialists. And it's funny because I equate us to primary care. Like, going back to my talk with Dr. Pierce a couple months ago, he always tells me every time I see him, he goes, you guys are better than primary care because you refer and you guys understand, like, not all of us, but we understand that our relationships with our patients are huge. And we have a close bond with our patients because we touch our patients, we see our patients on a regular basis, we build a bond with our patients that most primaries don't. And that builds a trust with our providers and makes us portal of entry, primary care, whatever you want to say. But I'm not treating any cardiac issues. Somebody has AFib and they're coming in my office. I mean, I understand it, I get it, but I'm not delving into it. Yes, diabetes. Can you help manage it with exercise and diet? 100%. Should you tell Miss Smith to get off her metformin for it? Absolutely not. Okay. So, never go outside what the referring provider is going to ask you to treat. Don't do it. If they've sent you for low back pain, if there's a shoulder issue, that's fine. Keep them in the loop. Do it. But if they have hypertension and they have diabetes and they've got cardiac issues, don't. Just, just don't. Okay. Keep it in mind as you're treating your patient. Keep it in mind that it might affect how your patient responds to treatment, but don't start treating that. Okay? Co-manage that with other providers. Co-manage that with the cardiologist. Co-manage it with the primary care. Co-manage it with the general surgeon, 100%. But don't take the reins on that. Never instruct a patient to stop seeing their primary care or getting off their medication. I feel like I shouldn't have to say that, but I have to say that because I see it too many times where that's a common occurrence. Never talk about medication. That's outside of our scope in all 50 states. Never talk about getting off meds. That's getting you in a whole world of hurt and problems that's completely outside your scope. Don't even think about that. If you feel like there's some kind of overmedication or there's an issue that maybe Miss Smith's seeing multiple providers and getting the same kind of a medication, or there's some issue there, I would bring that up to the primary care. But like, hey, I noticed Miss Smith's on this, this, and this. Did you know about this? Is that something you're concerned about? But you leave it at that. Don't take them off medication. Always let the professional take them off medication. Obviously, never pull a patient out of their— away from their provider. If a patient— if a provider refers you a patient, don't try to steal the patient. It's just, it's not polite. Like, I don't know what else to say to that. Keep it simple. Stay in your lane. Okay, like Kermit says here, it costs $0 to stay in your lane and mind your business. Do what you're good at. Stick to the neuromusculoskeletal. Anything else, be aware of it, understand how it's going to hinder your care, and co-manage it. So the first part of this presentation, I spent a lot of time talking about referring patients, getting referred to you. But what about using your patient base as a referral source? I learned early on in practice, we make the best neuromusculoskeletal providers. I'm going to tell you right now, and I sent this link to an orthopedic surgeon friend of mine, and I'm like, you got to watch this. I'm doing this at 2 o'clock today. Watch this, and I'm hoping he's going to watch this, and I'm going to say this knowing he's going to watch it. When it comes to neuromusculoskeletal, there are no providers better, and I include orthopedic surgeons in them. And what I mean by that is orthopedic surgeons are great, and if you find an orthopedic surgeon that's a great surgeon, you, you, you stick with them. All good, all good orthopedic surgeons will only do surgery when they think what they're going to do is going to help the patient, when conservative has failed, And most importantly, when surgery is not an option. And there's a lot of times surgery isn't an option. And that's why I say we're better at neuromusculoskeletal because we're not just one-trick ponies. We're not going to just cut somebody and that's not what we're doing. We can provide them better care in a holistic, non-surgical way, non-drug way to help actually fix underlying problems without having to cut a patient. And that's what I mean, we're better than— Dr. Balk, if you're going to see this— neuromusculoskeletal conditions. That being said, when it's surgical, the surgeon's gonna get it. And that's what the surgeon wants to see too. They want it when the conservative has failed. They want, they wanna know when it's surgical, that's, they're ready to roll. But we're not so great at other issues. Yes, we're trained in cardiac issues. Yes, we all took GI/GU classes and all this stuff, but we're not great at them. So don't, don't delve into it. When you do your intake, when you talk to your patient, always ask about comorbidities. Are you diabetic, hypertension? Always have them fill in a med, even though we don't do medicine and we may not know the medication. I have it. What medicine are you taking and what are you taking it for? Okay, so diabetes, that can affect stuff. Heart conditions, that can affect neuromusculoskeletal. High cholesterol can affect it. Statin drug use can all affect what we do. So asking about comorbidities, even without thinking about referrals or co-management, they should be part of your routine anyways so that you know how their health is going to affect the treatment you're providing. Always ask if they have a primary care provider. Please do. I'll go through the med list. I have it on my intake forms. Who's your primary care? More importantly for those comorbidities, if there is a condition there that's going to affect your treatment or how they're going to respond to your treatment, you want to make sure that's being actively co-managed. You want to make sure that Mr. Smith, who's a diabetic, is getting regular checkup or is hypertensive. He's seeing his primary on a regular basis and making sure that's controlled. If it's not, okay, we have to be made aware of that. So ask about a primary care. If they have a primary care that they see on a regular basis, you know what? 3-letter approach. Send them letters. Hey, you know what, Dr. Smith? Mr. Jones has been seeing me. He came, he came to me for low back pain. I just want to keep you in the loop that this is what I'm doing. This is what I'm seeing them for. This is what I'm planning to do with them. I also told them that if there's any issues that I can't handle, if there's a problem or changes, to reach out to you. Okay. 3 letters. Initial, reeval, final. They didn't refer the patient to you, but you're now using your patient base to make a relationship with a primary care that they may or may not— you may not have a relationship with. Again, The more you do that, your name gets out there. It also shows common courtesy. And the reason I like that is I see Mr. Smith, I get his low back better, back pain better. He sees his primary in 6 months. Primary goes through the file, says, hey, you saw Dr. Francis for your low back. How's that going? Oh, it's wonderful. It opens the door for that patient to sing your praises and to be like, he was wonderful. He managed my condition. I got better in 6 visits. I— it was a miracle. Whatever wording they want to use. The primary is now aware of that. And you know what, that primary may never refer that patient to you, but you know what, guess what they're going to do now? Next time the low back pain— after Mr. Smith, it's whoever the next patient is with low back pain. Hey, you know what, Mr. Smith just saw this patient, said he was wonderful, give him a try. It builds a relationship. Using your patient base to build a referral network of providers is a wonderful tool that we can use. Again, it's simple. And I'm going to say this. I don't spend any money on marketing. My marketing is zero and it has been for a long time. Initially to build patient base and build my patient base, yes. But now it's a self-referring system. My patients that I get are urgent care patients that are referred from the urgent care, from the providers I work with, orthopedic surgical referrals, hospital referrals, and my preexisting patients. I spend nothing on marketing. My marketing budget more often than not for these places is literally zero. And I still do some minor marketing on my Where I have an associate, yes. But for the most part, my marketing budget is actually zero. And I, between me, myself, I see about 150 patient visits a week. Okay. I see about 25 to 30 patients a week at the urgent care. I'm seeing now 30 patients every time I'm here. Hospitals, about 20, 25. So I see patients, but I built my referral network based on using my patient base and using referrals that are coming in to generate more, a bigger patient base. When you ask if they have a primary care, if they don't have a primary care, it's a perfect opportunity to build your— to use your network to get those primary care. So I— one of my good friends, he's a physician's assistant. He's been in my office. He sees patients in my office. I work with him in the urgent care, work with him at the hospital. When they're hypertension and they haven't seen a primary care in 2 years, and a lot of people don't, I use Mike. Hey Mike, I got a patient here. This is the situation. Do you mind? No problem. They got digestive, they have IBS, they need a scope. This is stuff I'm not doing. I'll take care of low back. You do the rest. And it builds that network. So by co-managing with other providers, it's gonna help facilitate helping your patients in a holistic way. You're not gonna treat diabetes. You can help manage it, but their diabetes is now in check. Your patients are going to love you for it. You're thinking about them. You're not just thinking about their low back pain. You're thinking about their overall health, and they love that. Keeping in mind your specialty is neuromusculoskeletal, okay? That is your specialty. Stay in your specialty. Once it goes outside of that specialist box, it needs to be referred. Primary care is not dealing with AFib. Primary care is sending AFib to cardiology. You should be in that same mentality. You refer patients when needed, when it's appropriate. Okay, I'm not saying refer every patient for an MRI, for imaging, for expensive testing, but when it's appropriate, you need to do it. When it's in the patient's best interest and their health is on the line here, you need to do it. That is what we should be doing for all of our patients. Yes, we're great with NMSK. But if they have IBS or they have Crohn's disease that's being not managed, you're doing them a disservice by just treating their low back pain. So keep that in mind. When approaching medical providers, these are the things I want you to look for. I want you to understand that when you're thinking about your network, when you're trying to build your network, you can't be going— and I use this example a lot. I got lucky with the hospital I worked at. It's a small hospital. It's considered a middle, medium-sized hospital in Cleveland, and Cleveland's got the Cleveland Clinic. So you want to make sure the providers you're approaching, you need to understand most of them are institutionalized. And what I mean by that is they're usually affiliated with the hospital. Usually the bigger hospital systems employ a lot of providers that are taught to keep it in the family. So primary care, their back pain has to go to the hospital's PT department. Okay? So those are harder nuts to crack and that's a harder network to build. So when you're trying to build your medical referral network, you want to work for solo practitioners, providers that are Not necessarily part of big hospital systems. They usually have more freedom. So you need to do your homework about these people first. If you're going to approach primary care down the street, you've got to do some homework for that. By understanding how they're structured also, you also understand how you can facilitate and help complement what they're doing. So try providing providers in smaller hospital settings. There's not a lot of primary cares that are independent still, but those are great providers to work with because they're not tied to hospital system. They're driven. And then understand there's always a risk that if you send somebody to somebody, yeah, they might get stolen. They may not come back to you, and they may not refer something back. That's okay. Because as you go through that and you deal with more providers, there are going to be providers that can send patients back, and that's how you build your network. So you definitely want to do your homework and understand who you're approaching and kind of where they're coming from before you make that introduction. Okay, so do your homework. You need to do your homework about who you approach. Understand how factors of how long they've been in practice, Specialty, patient demographics, their location, hospital group, and all those things. Try finding providers that work with you. Not to be— I don't want to throw stereotypes out there because I definitely don't think this, but in my reputation, medical doctors that went to school 30, 40 years ago tend to not be the most chiro-friendly, okay? Not as open-minded. They're set in their ways. Now, that being said, Dr. Purce, who I mentioned multiple times before. Dr. Purce graduated medical school back in the '70s. He's a general surgeon. You know what? But he's very open. He was very open to chiropractic. He loves chiropractic. He loves the right kind of fit. But he also knows there's some chiros out there that aren't necessarily evidence-based. So you got to kind of be aware, usually newer practitioners, recent grads, they tend to have more well-rounded understanding of what we do. And those are typically easy— easier people to approach. But again, understanding you got to do your homework. When they graduated, What's their specialty? Are they hospital-based and all that? So you really want to do your homework before approaching these providers.

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All right. So one of the questions I see is, do you need a records release Signed in order to contact patients' PCP due to HIPAA. So I always ask the question verbally to my patients, is it okay if I reach out to your primary care providers? Typically the response that I get is— and the way I explain it to my patients is, hey, you know what, if it's okay with you, I'd like to reach out to them. And the approach really is, I want to reach out to them. I want to keep them in the loop. I want them to have— so the next time you follow up, I want them to have the whole picture of what's been going on since the last time you saw them. So I want to reach out to your doctor because I want them to know what's going on with you. And I don't want you just— if you're not seeing them for another 5 months, I don't want you to have to remember, oh yeah, by the way, back in May I saw Dr. Francis 4 times. I'll reach out to them, let them know what we're doing, kind of approach them so that way next time you see them, they know what happened over the last few months and you don't have to remember that. And 99.9% of the time, actually 100% of the time, they're like, yeah, sure, go ahead and send a letter. You don't— as long as you have some kind of permission, you can have them sign like a little HIPAA compliant, I'm going to release. But also remember, you're not necessarily divulging any real health information. Like, you're, hey, low back pain. But you should definitely get some kind of consent from the patient. It doesn't have to be a full HIPAA release. It could be like, I had a little form drawn up of, if it's okay with you, I'm going to reach out to your primary and they'll sign it situation. But that's something definitely that we can own. That's a good question.

I have another question here. So a lot of discussion is happening right now within the healthcare community about the psychosocial aspect of care. Do you find that it's been important for you in practice to also have a relationship with mental health professionals for those patients you encounter that have pain that is being exacerbated by some things going on in their life outside of the physical?

100%. So I do have, being part of the hospital, I have psychologists and psychiatrists available. And I have, and usually what I'll do with those is usually I'll make a direct referral. A lot of the times what I'll do is I'll refer back to the primary or to one of my physician's assistants. I'll be like, hey, We're dealing with the low back, this aspect of it, but I think there's a mental component. I think there's something else going on. I think we have to address this other issue. The good thing is most primary care providers are comfortable enough to start the process on the mental health, whether it's giving them a low dose of anti-anxiety med, depression med, or something like that. And if they're not comfortable, they know to refer accordingly. So I definitely implement that, the whole psychological approach, especially my chronic pain patients. Then I definitely keep— I'm not a proponent of medicine, obviously, because of what we do, but I also understand the importance of that. So I'll definitely refer back to one of my psychologists that I have kind of in my back pocket. But like, hey, I also have a nurse practitioner at the hospital that I work very closely with. She's part of our integrative health department, and they do a lot of chronic pain, and they have a psychologist, psychiatrist. They do the mental health aspect. So I'll kick it back to them. But I 100% believe, especially when I'm dealing with a condition that it's not responding as well as I was expecting, And I feel like there's some kind of psychological component, I would definitely refer back to psychologists or primary care and be like, listen, I'll deal with the musculoskeletal, I'll deal with the actual physical problem, but I definitely think there's a psychological component. And I'll have the conversation with my patient if I feel like it's a chronic pain issue. Even if before I start care, my initial consultation, I'll be like, you know what? This is what I can do for you physically, but you've been in pain for so long that mentally it's going to take a toll on you. You've been in pain going on for so long. I tell this little smartass comment where I'll be like, Ms. Smith, if I was in your shoes and I've been suffering with this for 6 months, a year, 2 years, 5 years, whatever the case is, if you came into my office and you're all happy-go-lucky and you thought this was the greatest day in the world, I would think there's something wrong with you. That's not normal. What you're going through, I found in practice, you've had this going on for so long. I think there's another aspect we have to address. I'll deal with the physical, but you've been dealing with this for so long and there's a mental aspect that we have to approach. And then I'll make the appropriate referral again. Depending on where the patient came from, it was one of my primary care patients, I would send it back there. And then what I would do is I would also include a psychiatrist, psychologist, because I like to do acute stuff. I get acute pain under control, but there's always a mental aspect to it. And you have to really gauge that on initial consult because it goes back to the barriers you're going to face as a provider. Like, you— I expect my patients to be objectively, measurably better after 6 visits because in my clinical experience, what I've done for these conditions has shown this kind of response. Now, There's always complicating factors, but it doesn't go past the physical. There's also that mental aspect that as practitioners we have to be aware of. So definitely building that psychologist, psychiatrist, primary care mental health is incredibly imperative for what we do. And it— because early on in practice, like, I'd be doing these with patients and something got better, and I'm doing the same thing, and like, this patient isn't getting better. And I, I felt like a terrible practitioner, and it became frustrating for me. And then I realized When I started doing the pain management part or understanding the psychology of pain, that psychosocial stuff, I'm like, wait a sec, there's more than I can't help with that I need to address. And once I implemented that, especially with my chronic pain patients, it made a world of difference. So definitely the psychosocial is a huge part of what we do.

Absolutely. Someone else was asking, when initially trying to kind of get your foot in the door and start a relationship with a medical provider, Do you find it best to start with a phone call, an email, or stop by the office in person? Like, what is kind of commonly accepted within medical?

So here's the deal. There, there, there isn't a right approach. A lot of it has to go with your comfort too. It's, I'm an outgoing personality. I have a type A personality. My wife made the joke when I first met my wife's family, it was at a funeral. And like, I met all of them and I was, for lack of a better term, the life of the party. But it doesn't fit well for everybody. It really doesn't. So you have to find what works for you. If you're a very timid person, if you're a very shy person, that first step might be an email or a call or something along those lines. I'm a person, if every orthopedic surgeon at the hospital I've met in some way, shape, or form, and I've walked up to them in a room and I was like, hey, I'm Dr. Francis, this is what I do, I've heard great things about you, or whatever the case is. But that's not enough for everybody. So what works best is really what works best for your personality. If you need a little bit of a warming up to kind of get it going, Then maybe a phone call or a text. And I would also tell you, in busy practices, don't waste your time with the first introduction being with the medical doctor or the PA. Go through the office staff first. Go through the office manager. Go through the front desk. Bring a box of candy, muffins, Panera bread, St. Louis bread coming right from the country. Do things like that to make the introduction. But again, go with your personality. Like, I don't know how comfortable some people would be. Hey, I'm coming by your office. You've never met before. I want 10 minutes of your time for all of you. So it doesn't work for everybody. There is no right approach. It's what works best for your personality and what you need to get there. Mine has always been I'll show up at somebody's office and I'll just start talking to them. That's just, that's who I am. I'll start cracking jokes, being personable, but that doesn't always work well. So for me, what worked was initially was the letter approach. So getting letters in, getting my foot in the door, followed up by an email, a phone call with the office manager. I'll call them up like, can I speak to the office manager, whoever's in charge for the staff? And I'm going to tell you right now, 99% of medical providers have no idea where their patients go. That's usually the office staff approach. So dealing with the office manager, secretary, medical assistant is usually the best approach. So sending a letter is a great way to get it going. Calling them, be like, I appreciate your referrals, or I want to give you guys some donuts or whatever, the coffee, whatever. Can I drop some coffee off? That's usually the best way to go. And it's never— the one thing I want to say, this isn't a one-time, I'm going to show up to John Smith's office and get 100 referrals. This took me years to build to the point where I am now, and it's a slow approach. So starting off slowly with an email, a text message— I mean, I'm old school, you can send a fax if you want. I've done that. I still do that sometimes. Weird. But building slowly and just building on that relationship. So it goes off with what works for your personality. Again, most MDs, like, they don't— everything goes through their office manager. So you want to sweet-talk the office manager and the staff and then get in with the MD. So I found showing up in person, schmoozing with the staff, cracking jokes, deal with the MD worked for me. But that doesn't necessarily mean that's gonna work for everybody, but that usually is the best approach.

When you're talking to medical providers and they bring up the fact that Spinal manipulation is considered has quote unquote low quality evidence. What is your response and how do you kind of handle those tough conversations?

Oh, that it's either that conversation or what you do causes strokes. Those are my 2 favorite conversations to have. So my approach is always this, and it goes back to, I don't want to— chiropractic to me isn't just manipulation. Do I manipulate all my patients? Yes, maybe except for a few, but I pretty much manipulate in some way, shape, or form all my patients. But that's not just what I do. And it goes back to the evidence base. So when they mention up the low quality evidence, I mentioned that that's not all I do. I also, as a physician-level service, I'm also doing therapeutic exercise, neuromuscular reeducation, dry needling. Low quality evidence, yes, it might be low quality, but it does work for people. And I won't know if it's going to work for your patient until we try it. But I also do the high evidence stuff that I do home exercise plans and cardiac— not cardiac rehab, but building up cardiovascular stuff and managing all that. You really want to just avoid chiropractic as just manipulation, and that's not how I practice. It's funny because the orthopedic surgeon that I work with, he's a DO. DOs are trained in manipulation. He doesn't manipulate, but he also sees the intrinsic value of manipulation, but he also knows that's not— that's one piece of the puzzle. So your approach is— and how I differentiate myself from the PT is, okay, you can send to the PT, they're gonna do therapeutic exercise, and I have PTs in my office. I love PT. But by using us first, you're now having a physician-level service monitor the patient, examine the patient, track the patient. So the PT can just do what PT does. Like, you give them a script, I want these exercises done. That's all they can do. I can go one step above and I can diagnose the patient. I can order imaging, I can order testing, and then I can still do what they do, but I can also do the physician stuff. And it doesn't necessarily just have to be manipulation or heat or acupuncture because I do evidence-based, I do therapeutic exercise. I do trigger point massage and I do ART and I do all this stuff. And to me, I don't avoid the question. I kind of play it off as it may be low evidence, but it's worked for people. I'm not going to know if it's worked for your patient till we try it. If I try it on your patient and it doesn't work, then guess what? I'm not going to do it. I'm going to do something else. And that's what they want to hear. And it's funny because the stroke talk is another talk I don't want to go into, but it's one of those conversations that you have that's Yeah, it might be low evidence, but the evidence is constantly changing. Most of the medical stuff that you do is low evidence, but you still do it because you're trying to see what works for that patient. This isn't an exact science. 2 L4-L5 disc herniations herniating the exact same way in 2 different patients is not going to respond to the exact same treatment in the exact same way. This is a trial and error thing. So I'm going to try some of the low evidence stuff, sure, but I'm going to mix it with high evidence stuff to see what works best for your patient. And that's what they want to see. They want— they don't want the cocky chiro that's going to say, well, I'm going to do this, and this is my, this is my cookie-cutter treatment plan, this is what's going to work. Because they're going to look at you and think, well, not everything works the same for every patient. So you can implement some of the low evidence stuff. Yes, manipulation may have low evidence stuff, but it works for some people. And I'm not going to know if it's going to work for your patient until we try it. And I get a lot of the patients referred to me that have failed PT. For a lot of my newer providers, Until they realize that I can do a PT, like we can do it just as well, if not better. They failed PT, can you figure this out? Okay, well, the high evidence stuff didn't work. So let's try low evidence stuff, maybe that's gonna work. So there's different ways of dealing with that low evidence approach, you just have to spin it to make sense to them.

Absolutely. You kind of mentioned the emphasis on really making sure you do some type of reevaluation with your patients. Are you utilizing any of like the yellow flag questionnaires? Do you really emphasize those outcomes measures? And is that something that you would also send as part of that reevaluation report or mainly just give a general briefing there?

So I'm a big fan of functional outcome assessments. I'm gonna give a shout out to Greg Friedman. I've taken his class. I consider him a friend. He taught me a lot about documentation, but the functional outcome assessments to me is the gold standard. Here's the thing, I may not even do a formal reevaluation on every patient, the 99212, 213 coding. Like, I mean, I have to do that. My reevaluation might just be functional outcome assessments. And then when I communicate with the providers, with the primary care providers who are referred to me, I'll put in there, hey, you know what, initial visit, our functional outcome assessments had this rating. We noticed a 45% decrease after 6 visits. That's language they understand when you can put a number on it. So for me, a functional outcome assessment is much more important rather than doing something like range of motion. Okay. So On visit 1, she had 20 degrees of range of motion flexion, but now she has 35. Providers are gonna be like, that's 15 degrees. That doesn't seem like a lot. I mean, that's a lot to us, but to primary care, they're like, what are you talking about? But now if we talk about functionally, she— we notice a 45% improvement in functional rating. They're like, oh, that, that's impressive. Like, so I'm a huge believer in functional outcome assessments. And again, I may not even do a formal reevaluation depending on how my flow is going. But you sure can bet that I'm going to do my best to get a functional outcome assessment at visit 5, 6, 7 from the patient. And then I'm going to compare it. And I tell my patients, I care about your pain, but I really don't care about your pain. What I really care about is your function. Like, how are you functioning? I need to know that when I first saw you, you couldn't bend over to tie your shoes. And 4 days later, you're— or 4 visits later, you're bending over, tying your shoes, putting your shoes on, no pain or some pain. I never let pain dictate. And I had that conversation with my patients earlier. Like, I care about your pain. That's why you're here. But what I really care about is your function. Pain scale, so I'll be like, visit 1, you're 6 out of 10, but you couldn't do anything. But now you're a 10 out of 10 or an 8 out of 10, but you know what, you played with your grandson, you were able to play basketball, play volleyball, go for a run. To me, that's a win. And that's the way I'm going to approach that. So functional outcome assessments for me are huge. And then when I relate it to the provider, I talk function more than I talk pain. I talk about, we were able to get her back to working out, even though she still has pain, she's functionally more better. I implement those, whether it's a 45% decrease in pain, like a number, or whether it's just discussing the functional improvements I found. That's really what I try to balance. But functional outcome assessments, huge in my practice, is huge. Or asking about ADLs, mentioning, hey, she can go work out at the gym with no pain, or whatever the case is. So you really want to mention function. And I wouldn't necessarily use those raw numbers, but I would mention a 45%, 30% decrease in overall function, or Or pain levels or whatever the case is. Awesome.

Absolutely. So I'm going to ask one more question and then, but another question we had was, have you ever encountered a situation where you refer to a PCP and then they tell them they shouldn't see you anymore or that chiropractic is not something that they should be utilizing? And how do you handle that both with the patient and with the provider?

Oh boy. Okay. So I don't get that much anymore based on the referrals I make is within the hospital that I work in. They all know me. But early in practice, I got that. That happens. It happens. There's 2 approaches here that I kind of use on this. So it all depends on why the provider is doing this. I'll always make a phone call, be like, hey, Dr. Smith, I referred you this patient. I understand you told them not to refer to me. And I have no problems with that. I just need to know your logic behind it. And you can spin it with, did I miss something? Was there a red flag I didn't catch on? I just want to make sure that What's your reasoning? There's 2 answers you're going to get. It's either going to be like, well, there's some kind of issue that I feel like you might exacerbate, and/or I think there's an issue if you manipulate. I don't want to go high velocity on them. I think there's another issue. Or the response you're going to get is, you're a quack and I don't believe in what you do. And that's what it is. Depending on the response that I get, now, if it's the quack comment, you're going to have to chalk it up as a loss. There's no There's no trying to change their mind. There's no beating them with information. There's no reason to get aggravated, upset. It's not worth the battle. You're 99% of the time, it's going to be wasted energy. You're never going to change. They have that preconceived notion that what you're doing is dangerous. You're a quack. You're not a doctor. You're, you're terrible. Whatever they believe is what they believe. You're not going to change that with one phone conversation, or you're not going to change that with any issue with anything like that. If the response is, I think manipulation is going to be dangerous for the patient. I think there's an issue with that. Your typical approach should be, listen, I respect that approach, and I'm not saying that's not a concern of mine, but what I do is not just manipulation. I'm going to do some therapeutic exercise. There's stuff we can do away from manipulation, like getting the mentality that because we're chiros, we don't just manipulate. Like, yes, that's a piece of the puzzle, but we offer so much more. So it depends on the response you get. I've, I've heard stories of— it's funny because I had this conversation actually recently. Quick story. So I was working at the hospital. Dr. Purce referred me a patient he did abdominal surgery on. He was having a low back complaint with radicular complaints. And then he was like, do you want to do trial of care before we do an MRI? Because he put in for an MRI. The insurance company said, well, we need failed conservative care before we do it. And so I did a trial of care and I noticed radicular was getting worse. I wasn't doing anything high velocity with him. I was doing some soft tissue stuff. I was doing some activator. I was doing a little acupuncture. He was getting some relief, but radicular was getting worse. So I kicked it back to Dr. Purse, who's a general surgeon. I'm like, listen, Dave, I go, we need to get imaging. I go, we need to admit him because it's getting out of control and I don't want him waiting any longer. So he's like, okay, we'll go ahead. We co-admitted him. We admitted him to the hospital. He saw one of the neurosurgeons who's good friends with Dr. Purse, and he ends up doing a discectomy and decompression the very next day because it was getting bad and the radicular was getting bad. And as he's walking out of the hospital, he stopped in my office at the hospital and he came. He's like, hey, I did surgery. I'm like, I heard whatever. So I didn't come visit you during surgery or Or post-op. I was a little crazy, whatever the case is. And he's like, can I come and see you? I'm like, well, yeah, I'm not going to manipulate you. I'm not going to do anything crazy. I'm going to— he had, I think it was L4-L5 or L5-S1. And I'm like, I can do some acupuncture to manage some of the post-op pain. We can do a little ice, we can do some interferential. We're not going to do anything too active, too crazy, too soon, but we can at least help postoperatively get the pain. So he followed up with me a couple of days later once he got settled and whatever. And it's funny because it was L4-L5. I did Activator on him, like, Mid-thoracic, maybe thoracolumbar junction, and maybe the SI joint. And then I did acupuncture for post-op pain, and I did a little passive with them. I did nothing active with them. And I get a phone call from the physician's assistant of the surgeon, and she was like, listen, I don't know who you think you are, and all this stuff. She goes off on a tangent. I'm like, listen, I go, I'm not doing anything. I'm doing nothing at the surgical site. I understand what was done. I'm not high velocity. I'm not side posturing this person 4 or 5 and cranking on them. I'm not doing anything stupid. I'm managing post-op pain and I'm manipulating like well above it and well below it to keep, keep motion going. And I wasn't fazed by that. I deal with it all the time. Well, you're a chiropractor, you manipulate, said manipulation in your documentation. I'm like, no, no, I did low velocity, nowhere near. And my documentation clearly says that. And it's funny. And I just, I'm like, listen, I go, the patient can see me. If you don't want the patient to see me, I respect that. No problem. And I go, but you need to realize I admitted the patient with Dr. Purves. Like we co-admitted this. I know what's going on. You're the reason The surgery had— like, we're the reason the surgery happened. Yes, you did the surgery. And it was funny because I got off the phone and I walked to my back office and Dr. Perse was back there. He's like, what's going on? And I told him, I go, I'm not upset with it. I go, I understand, but I'm kind of offended that they told the patient not to see me even though I wasn't actually treating the surgical area because I'm not stupid. Like, give me some clinical credit. He got so aggravated and so mad, he literally left As soon as clinic was over, he was done with his patient. He actually had a patient in office. He went upstairs to the surgical floor, found the surgeon, and literally, who was a friend of him for 20 years, told him, don't fuck with Dr. Francis. He's not stupid. You need to call him and apologize. He was— Dr. Purce was more aggravated that that happened than I was. It's, it's part of what it is. And, and you have to not take— and I took none of it personally. I didn't tell him to go give him crap and go yell at him, but he took it upon himself to go do it because Clinically, once they know what you can do clinically and that clinically you show that you can, you're not just manipulating a dangerous part. And it's funny because 3 weeks later, guess who referred me a patient? The neurosurgeon. Okay, so it's not— it, it, you can't get mad at it, you can't get aggravated with it, and you can't take it personally. It's the stigma of our profession. But by having understanding what you're doing is clinically relevant, you're smart about it, you're, you're following guidelines, you're not doing anything stupid. They'll have their preconceived notions, but then as you start doing your job, your reputation follows you and people will fight for you. And then you don't have to fight that battle. You— I got gray hair and I'm barely 40. You don't need that aggravation in your life. And you just have to understand that you have to respect their opinions. And if their opinion is you're a quack, can't fight it. You're not gonna, you're not gonna win it. Now, your reputation, eventually they'll hear of what you're doing and they're gonna wanna work with you. And if they don't, that's their loss and their patient's loss. If they wanna prescribe them and do whatever, that's fine. You have to understand that you can't be combative. You can't get angry. You can't get upset with it and take it personally. It just, it is what it is. And you will, you may lose patients you refer, but reaching out, being professional, being calm, understand why they said it. And if it's something that leaves the door open for communication, use that to communicate. Use it to be like, I understand you're concerned about manipulation because of X, Y, and Z, but that's not just what we do. I'm going to provide physician-level services. I'm going to monitor them and do therapeutic exercise. I'm going to make sure what we do is evidence-based and safe. And that can go one of two ways. Either they're going to be like, okay, they can see you again. And 9 times out of 10, if that's the approach and that's a concern, they'll send the patient right back. If it's because you're a quack, you're not winning that battle that day. So just understand that's a risk you might have to take. But it surprisingly doesn't happen as much as you think when you ask that extra question, make that phone call and try to communicate. And usually resolves pretty quickly without Absolutely.

Thank you so much. So I think this has been a great discussion, and I think there's definitely room for possibly a part 2 on— in the future, because there's so much to unpack here.

Oh, there's so much going on here. Yes, I mean, 100%.

Be sure to tune in for episode 57, where we'd kick off a new training titled Creating an Effective Prehabilitation Program with Dr. Davis McAllister. In this 2-part presentation, we'll discuss the evidence-based components that every prehab program should have. We'll dive into the research surrounding ACL injury, as well as discuss the application of force and movement as it relates to injury prevention. You won't want to miss it. Episode 57 drops in 2 weeks. Now, before we end today's episode, I have a quick favor to ask. We're working on some exciting new things at Factor. And while I can't yet announce everything, what I can say for certain is that our team is continually seeking new and innovative ways that we can serve our global network of healthcare providers and students. After working with healthcare providers across the globe for the past decade, I feel like I have a pretty good grasp on the biggest needs of our community, but I never want to make assumptions and miss the mark. So in the spirit of making sure we're heading in the right direction, head to the show notes and click the link on our factor survey. It contains just 5 simple questions to help us zero in on exactly what you need most from our team. It will take less than a minute to complete, and I will be ever so grateful to have your feedback. Now, it doesn't matter if you've taken a factor course before or not. It does ask you that there in the survey, so please be honest and let us know if you've ever taken any of our live courses, our online courses, or maybe you're just an avid listener of the podcast and still kind of figuring this whole factor thing out. As a thank you gift, I'll send you a cultivated playlist of our best factor podcast episodes and provide some content that's custom tailored to your submissions. So go to the show notes, click on the Factor survey link, or visit our link in bio on Instagram. I read each and every one of the responses personally and am very excited to hear your feedback. That's all for today. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-O-R dot com. R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.