Thursday, August 27, 2009

Stupid Until Proven Intelligent - MD & DC Relations

Dumb and Dumber: Original Motion Picture Sound...Image via Wikipedia

Around 1986-7 I was the medical director for a track meet at West Point. At that time I was in charge of all medical care for all of the Metropolitan Athletics Congresses events. I must have worked at 40-50 track and cross country events a year.


Whoever was a top US 100m high hurdler fell and hurt her leg. The pain was on the lateral side of her lower leg. A tuning fork test suggested an unusual fracture one of the fibula. The tuning fork test is where one puts a 128Hz turning fork on a bone with a suspected fracture (not right over the site of injury) and the vibration is supposed to irritate the fracture side and cause pain.


I drove this woman to the base hospital and spoke to the admission clerk, reporting a suspected fibular fracture. The attending was standing nearby and overheard me. He said, “don’t you mean tibia?” I replied, “no, fibula.” He asked why I thought fibula. As I said this is not a common fracture.


I said location of pain and a positive tuning fork test. That of course provoked questions about the tuning fork. I said that it was a standard on-field screening test in sport medicine.


MD: “Sports medicine? That’s a specialty?”

Me: “I’m certified” {I was a CCSP (Certified Chiropractic Sports Physician - except due to NYS bizzar rules I was supposed to call myself a Certified Chiropractic Sports Practioner}

MD: “I didn’t know there were fellowships in that?”

Me: “I did post grad training”


He then asked if I could show him how to do it on a woman just brought in by ambulance. She crashed on the base ski run. He had to get a nurse to unlock the cabinet with the tuning forks. They had the box set with every frequency. I took out the 128Hz and showed him how to use it. Later after my athlete’s radiographs came back negative we talked some more. He asked what hospital I work at and then I said, “I don’t, I’m a chiropractor.”


Lindsay Rowe, DC, MD taught me this "technique" to deal with medical prejudice towards chiropractors. He said that to many MDs you are stupid until proven intelligent if they know you are a chiropractor. So prove you are intelligent and then let them know you are a chiropractor. I’ve used it often to great effect.


The example Lindsay gave me was that before he went back to get his medical degree, he used to travel the US. Wherever he was he'd call the local medical school and try to speak to the head of radiology department. On the phone he would introduced himself as a radiologist from NZ with interesting cases. Lindsey is a board certified chiropractic radiologist. {BTW two studies have shown that chiropractic radiologists (DACBR) are as good as anyone else in reading skeletal films.(1, 2)} If he got to meet with the radiologist they'd play what I call, "stump the radiologist."


Then when they were done trying to stump each other he’d reveal he was “only” a DC. Lots of surprised looks. He was invited to give grand rounds a few times and audience was only told what his training was at the end. Most couldn’t believe it because of course we’re all dumb as door-nails.


I've used this technique for many years. Fortunately, I don't run into such overt prejudice as often as I once did. My favorite example was the MD at a cocktail party who upon hearing I was a chiropractor dropped my hand, mid-handshake, spun on his heels and walked away without a single word.


Because of my work with the ING New York City Marathon and the New York Road Runners I often come in contact with MDs and haven't had that kind of thing happen. I guess that means my profession is moving more into the mainstream of health care, but we have work yet to do to be completely in mainstream health-care.


SMP


1. Taylor JA, Clopton P, Bosch E, Miller KA, Marcelis S. Interpretation of abnormal lumbosacral spine radiographs: A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic. Spine. 1995;20(10):1147-54.
2. de Zoete A, Assendelft WJ, Algra PR, Oberman WR, Vanderschueren GM, Bezemer PD. Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists. Spine. 2002 Sep 1;27(17):1926-33; discussion 33.

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10 comments:

  1. Randy J Ferrance, DC, MDAugust 27, 2009 at 7:54 PM

    Excellent article, Stephen. As a DC, MD myself, I've been through a bit of this. Though to be honest, I have been pleasantly surprised by how little discrimination I've run into.

    As a medical student at the Medical College of Virginia I was, at times, a bit hesitant to advertise my DC roots. But with only one exception (an academic orthopedic surgeon - how's that for an oxymoron?) my supervising physicians would comment on what a benefit it was to have both disciplines to draw from. I also felt that they often expected more from me, given my previous clinical background. When I applied to medical school there, I felt as if they were recruiting me, and the admissions office told me outright that they saw my chiropractic background, and my previous private practice, as an asset.

    The University of Va Medical School, on the other hand, dismissed me outright.

    So yes, there is chauvenism in medicine.

    But then, there is chauvenism in chiropractic as well. I've been called a heretic, a "non-believer", a traitor by many of my chiropractic brethren.

    Thanks for your post, Stephen. Your wisdom and insight are a tremendous asset to the chiropractic profession.

    ReplyDelete
  2. Great stories Dr. Perle! Having been in practice only 7 years now, I can honestly say that thankfully the state of interprofessional relationships between MDs and DCs has much improved from my experience. Early on in practice, I presented myself in writing to local PCPs as practicing evidence-based (EB) manipulation therapy, manual therapy and rehab exercises. One particular MD interested in the approach (a local educator) sent over several patients. Thus began a long professional relationship and personal relationship. We convene in this secular part of the world for "Sunday church" every Sunday to run to the top of a local butte and enjoy the view. Conversations often are shop related, and through the process, we've learned much about where our individual strengths and weaknesses are and how working together improves our patients' care. Thanks for your contribution a few years earlier in helping to lay the difficult foundation that allows this process to take place today.

    ReplyDelete
  3. Great story, Magic. While medical prejudice may be on the wane in some parts of the country, down here in Dixieland, professional chauvinism is very much alive, no doubt in part to Big $id's fiasco at Life Diploma Mill that too many people still remember.
    In fact, my wife admitted to me that she's afraid to tell her MD that she's married to a chiropractor for fear of retaliation of some sort. What makes this even odder is that he's from Palestine himself, so it appears we have a pecking order of prejudice where we DCs are on the lowest rung.
    I now know how Jackie Robinson must have felt being the best player in baseball but still subject to ridicule by racists.
    Keep telling us about your stories, please.
    Your faithful admirer,
    JCS

    ReplyDelete
  4. Randy,

    I guess one should not expect any kind of uniform approach from the medical professon towards chiropractors yet. I have a friend here in CT who went to DO school. Was given significant transfer credit even though he'd been out of chiropractic college for 20 years. He told me that in one class in his first he was to write up a case management plan for a patient that was presented. When the instructor returned the papers he asked who the hell was my friend. He raised his hand the the prof asked how did you know how to do this? His answer 20 years practice as a chiropractor. From that time on he set a higher standard for himself.

    Well you know well that I've been called a heretic too. Heck I sought you out to write a heretical paper on vaccination. Thanks for being a free thinker and still engaged in a profession that doesn't always "embrace its heretics" :)

    ReplyDelete
  5. Dr. Snell,

    Glad to hear in your neck of the woods the ice of relations between chiropractic and medicine are thawing.

    Not sure that I laid any foundations that have allowed this process. Although I did have an MD practice in my office in the late 80s, which for NYC was very early. He's still one of my closest friends.

    ReplyDelete
  6. Great story. While medical prejudice may be on the wane in some parts of the country, down here in Dixieland, professional chauvinism is very much alive, no doubt in part to Big $id's fiasco at Life Diploma Mill that too many people still remember.
    In fact, my wife admitted to me that she's afraid to tell her MD that she's married to a chiropractor for fear of retaliation of some sort. What makes this even odder is that he's from Palestine himself, so it appears we have a pecking order of prejudice where we DCs are on the lowest rung.
    I now know how Jackie Robinson must have felt being the best player in baseball but still subject to ridicule by racists.
    Keep telling us about your stories, please.
    Your faithful admirer,
    JCS

    ReplyDelete
  7. JCS,

    I think that the relations between the professions vary between country, region, state, and city.

    I used to say to my students, that if you aren't a member of a minority group that as a chiropractor you might come to get an inkling of what it is like to be a member of a minority. I remember when articles on racism in America lamented the lack of any people of color in TV shows and movies in roles other than as criminals and servants.

    For such a long time chiropractic was similar to that. There were no chiropractors on TV or movies unless they were in a 60 Minutes expose. Then came the movie Jacob's Ladder. And now there's comedy Two and a Half Men and the movie The Answer Man.

    Chiropractic has made positive strides but there is still room to improve.

    SMP

    ReplyDelete
  8. Stephen,

    When I first started chiropractic practice in 1982, I was definitely considered stupid until proven intelligent. I could not find a MD in private who would take my referrals or cooperate with me in any way.

    Fast forward to 2002, when I enrolled in a PhD program at the University of Pittsburgh and took a number of biostatistics courses in the Graduate School of Public Health. Now I was considered intelligent until proven otherwise; heck, I was accepted into the PhD program -- so it didn't matter about my previous education. No one really cared too much about

    When I would tell people I was a chiropractor, my DC degree was seen as an asset. Something that made me different; something that allowed me to provide a unique perspective on things.

    I eventually took a one-year certificate program in clinical research with the medical students and residents. In those classes I never experienced a single negative comment or slur; all the MDs were very respectful of me and appreciated having a DC/PhD in the classroom with them. Several MDs actually "looked up" to me as a role model of a clinician and researcher; something very, very rare in the medical world.

    So....times are changing! I think that way we are perceived by folks outside our profession is proportional to the perception we have of ourselves. If you know your stuff, and know that you know your stuff, the self-confidence is projected outward and people have confidence it you. "Who you are speaks so loudly that I cannot hear what you are saying".

    Michael Schneider, DC, PhD

    ReplyDelete
  9. for the past 10 years I have worked part time as a clinical instructor in the department of family medicine at the University of Rochester School of Medicine. All the first year residents in family medicine spend 3 or 4 1/2 day sessions with me in my practice. It is a passive experience for them but it does provide them exposure to evidence influenced chiropractic and broadens their training on musculoskeletal diagnosis. In these 10 years I have never met resistence from the family medicine residents relative. They have asked some very pointed questions, but I encouraged that. One of their most frequent questions was how they could identify a compentent chiropractor to work with once they entered private practice. I usually defer to comments made in this regard by Don Levy, MD from the Osher Insitute at Harvard: characteristics of a chiropractor MDs could work with -
    1. evidence influenced (rational)
    2. patient centered
    3. safe
    4. uses valid outcome measures
    5. cost effective
    Perhaps we could discuss what each of these variables means in practical terms ie. what does it mean to be patient centered, and how can we identify this characteristic in a provider.

    ReplyDelete
  10. I have worked as a clinical instructor in department of family medicine at University of Rochester School of Medicine for the past 10 years. All first year residents spend 3 or 4 1/2 day sessions in my office with me. In all these 10 years I have not met resistance from any resident. They appreciate enhancing their musculoskeletal diagnostic skills and most commonly ask me how they can choose a good chiropractor to work with once they enter private practice. I defer to the commentary by Don Levy, MD of Harvard's Osher Institute:
    1. evidence based (rational)
    2. patient centered
    3. safe
    4. use valid outcome tools
    5. cost effective

    where we might consider extending this dialogue, is in better defining what it means to be patient centered, and how can we identify those practitioners; what are the best outcome tools to be using for back pain, for headache, for extremity complaints;

    John M Ventura, DC

    ReplyDelete