This topic contains 5 replies, has 5 voices, and was last updated by Anonymous September 17, 2016 at 10:11 am.
September 15, 2016 at 10:07 am #3582
I recently had a shoulder case that came in that I was suspicious of some type of labrum degeneration at the time. On exam it was looking pretty clear that it was the case and the provocative movements put me down that path as well. He also did have some significant adhesion in the RTC. Cleared all the adhesion up and SA went from flexed 2 inches forward, and 3 inches from the head to fully touching. Now there was a significant decrease in the ST triangle and the patient was reporting more symptoms with everyday ADLs. He is also an avid crossfitter and someone who shouldnt be, but that is a whole other story.
After 6 visits we both decided that the conservative approach just wasnt going to get him much more in improvement and we were in the zone of diminished gains. I referred him back to his PCP ( hes retired military so he gets the great care of the VA) and went over the fact that we didnt just need a regular MRI but required the image to be arthrogram to help determine full extent of the pathology. I wrote a letter to the PCP and let them know several times the importance of getting the arthrogram.
And in true lousy fashion , they ordered the regular MRI and it came back clean, with the diagnosis of “impingement” and ” inflammation” of the shoulder.
Now the patient is considering getting some injections done to “wipe out all that inflammation” and wanted to hold off on coming back into me, he was nice about it, but I can read through the lines, hes disappointed in me because he thinks I “missed” it. Even though he didnt get the test he needed, I guess Dr. Brady is right when he says we are the top 1 percent and need to be an island of excellence.
I wanted to see if other docs have had issues with this and how they combated it, thanks!September 15, 2016 at 10:08 am #3584
Brandon Cohen DC, CSCSParticipant
I have no good answers for this. I can commiserate with you all afternoon. I have a recent experience with a patient who I diagnosed with labral tear at the hip. She needed to go through her ortho for insurance reasons for the imaging. He diagnosed her with bursitis, gave her a dose of cortisone and told her to do PT. I spoke with her on the phone and we discussed the importance of getting the MRA to see the actual problem, and that she might feel some relief from the injection, but long term will likely be better off. I cautioned her about physical therapy and the increased loading it might produce.
Relief from the injection for 2 weeks, and she went to PT for 2 weeks and the symptoms were back worse than before. She eventually pressed the ortho for the correct imaging which confirmed our diagnosis. I sent a letter to the office and with the patient about the importance of the imaging in the beginning. Unfortunately this is my 4th time dealing with similar things from the same orthopedist. I hope that my credibility can increase with the doc so they can trust the diagnosis and opinion.
I don’t know the answer. I’ve sent some case studies their way, but that hasn’t seemed to help. Maybe a phone call and some level of conversation might help prior to the patient’s visit? I’ve learn to assume that every provider has all their processes and think that I am likely some sort of an idiot. At this point, I feel the same way about many of the specialists I deal with. You can give them all the information in the world to present your case, and at the end of the day they are going to do whatever they want.September 16, 2016 at 10:09 am #3586
Scott King, DCParticipant
I just recently had this with a patient who wasn’t happy with how fast progress was going with her heel pain. I suggested ordering an MRI as soon as possible – her insurance would cover it at 8 visits from her podiatrist (Kaiser..). So I sent her to her podiatrist for imaging (rookie mistake), who had injected her with cortisone 6 time prior and did nothing to help her pain. Podiatrist told her that she has tarsal tunnel syndrome so she cancelled her next appointment with me to go back to her podiatrist for another round of injections, orthotics, etc. Despite the progress we had made in a matter of 9 visits (zero relief from heel pain while walking in past year – many days of no pain while walking since treatment, with plenty of flare ups in between)
Called her to tell her I’d like to get eyes on the film. So she will be bringing them in when she returns from a conference. She actually read me back the MRI findings, and they were 100% consistent with what I suspected and what Dr. Brady helped me to arrive at with coaching. Mild achilles tendinosis, and a tear in the plantar fascia( I was thinking cartilage damage between heel bones – which wasn’t consistent with her history as I learned via coaching). Essentially all of the work we have been doing was moving the needle in the right direction. It was the diagnosis and treatment that she badly needs.
The problem was my communication was piss poor from the beginning. And her respect for my expertise was lacking. She was a regular at the restaurant I used to bartend at and came in to see me through that relationship. From the beginning I did a poor job at getting her attention on her diagnosis, stating the severity of her condition, the progress we are making with treatment. I didn’t constantly reminder her that we are rebuilding her damaged tissue cell by cell. Instead I let her drone on about the latest Anthony Weiner scandal (who the f is that?), her latest blind date gone wrong, and how her kids hockey team sucks.
While I am not sure how this case will turn out, I am going to fight like hell for her future health. She isn’t completely gone yet. But despite all of our progress this lady respects the opinion of her trigger happy podiatrist much more than her neighborhood bartender/chiropractor. Some of it is her personality. Some of it was me not recognizing her personality type. Most of it was me not being focused enough in communication, despite of the disadvantage I was already starting at.September 16, 2016 at 10:09 am #3588
Scott King, DCParticipant
Oh and to boot, the podiatrist told her that the tear in her plantar fascia was actually a good thing, as that’s what they do with surgery for the type of pain she is having…September 17, 2016 at 10:10 am #3590
This is a very frustrating topic, and I have my share of very similar stories. There is no way to change the ignorance of some other medical professionals.
The conclusion I’ve come to is I need to:
keep working on communication between myself and my patient, the truth will come out eventually and this is when you build more credibility with others.
put all your diagnosis’ in writing like you did so that another professional can’t deny that you were on the right path from the start.
give the office of the other provider a call and ask for the Doc to give you a call back at his convenience to discus the details of the case. I even put this is terms of “I just want to make sure i’m on the same page as (said Dr), so I can continue to help this patient progress.” When i don’t get a call back, it confirms what this doctor thinks of me, and I avoid sending any future patients to them. After a while of doing this, you will find the doctors that think like we do, and you can help your patients by sending them there instead.
do everything I can to not get discouraged. this is what i struggle with the most. I just have to tell myself to give the other professional the benefit of the doubt. If it were any other DC in my area treating this patient, they would be 100% lost and doing a lot of things wrong. This professional just assumes I am like the rest, and only time and consistent results with my patients will change that.
Hope that helps. Remember – don’t take anything personally.September 17, 2016 at 10:11 am #3592
I agree with everything Brian said in his post.
I will just add to the “put it in writing” concept. Send the other doctor the practice standards from the American College of Radiology and your diagnosis. Clearly and simply state why the test is necessary. Specifics help- “a 10% increase in sensitivity for labrum tear” is way better than “it’s more sensitive.” See the article in the research section on Shoulder MRI: Contrast or not?
Just follow the standards, point out how you were initially correct and that after all the wrong turns you were right. This would have saved the patient months of poor care, deteriorating condition and expense.
If you are feeling generous make it about the practice standards rather than “good” doc vs. “bad” doc.
As for managing the patient, you have to bring all of your clinical swagger to the table. Don’t make qualified statements such as “maybe, I think, we probably should, etc…” Do say “We need to get and MRI with contrast.”
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