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

Factor spelled FA 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 six continents, serving as a framework that guides clinical decision making and 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 and help care in a short format that is easy 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 two part training on medical collaboration for the private practice Chiropractor with doctor Alex Francis. In part one, we got to know the medical model and how medical referrals work. We discussed best practices and approaching medical providers for co management of cases and chatted about the importance of addressing mental help 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 doctor Alex Francis, a board certified chiropractic orthopedes who owned several integrated health centers throughout northeast Ohio. A two thousand and eight graduate of Logan University, doctor Francis began his first multidisciplinary clinic soon after graduation, growing to three locations and employing a team of providers including a board certified orthopedic surgeon, general practice medical doctor, physicians, assistants, physical therapists, and massage therapists. In twenty thirteen, he became staff privileged with a local hospital in Cleveland and has operated an established office in the hospital since two seventeen, working with specialty teams such as primary care, general surgery, vascular surgery, and pedietry. Most recently, doctor Francis has expanded to integration with an urgent care facility offering chiropractic care as part of their model managing neuromuscular skeletal conditions alongside various other healthcare specialists. This two part training is going to provide you actionable depths 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 steam. Let's get started. So that's kind of it. So let's talk about co managinge care. This is a good topic that I always talk to students about, and I know we got a few students soon. I'm hoping more students watch it. Co managine care. God, I don't know how many times I see it. Where I talked to two different providers. I talked to myrathpedic surgeons, where I talk to my primmer at care and they tell me the story about how they send something to a cairo for low back pain and the Cairo 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 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. We get referrals, Caros 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 near muscular n MSK. Now where we are trained knowing gigu stuff. We're trained knowing cardiac stuff and lung stuff, and yes we are trained in that, but by no means are we specialist. And it's funny because I equate us to primary care. Like going back to my talk with doctor Person a couple of months ago, he always tells me every time I say, 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 bottom of our patients because we touch our patients, we see our patients stormy other basis, we build a bottom with our patients, and most primaries don't and that builds a trust with our providers and makes us portal entry primary care. Whatever you want to say, but I'm not treating any cardiac issues. Somebody has a five not 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? One hundred percent. Should you tell miss Smith to get off or met forming for it? Absolutely not, okay, So never go outside with the with the provider 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 got cardiac issues, don't just don't. Okay, keep it in mind as you're treating your patient, keep it in mind that it might affect how your tasing response to treatment. But don't start treating that, okay. Co manage that with other providers, co manager of the cardiologist, comanager with the primary care, co manager with the general surgeon. One percent. But don't don't. Don't take the reins on that instruct a patient to stop 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 that's a common occurrence. Never talk about medication that's outside of her scope in all fifty states. Never talk about getting off meds. That's getting you in a whole world of hurt and problems that completely outside your scope. Don't even think about that. If you feel like there's some kind of over medication, or there's an issue that maybe Miss Smiths 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? That's something you're concerned about, But you leave it at that. Don't take them off medication. Always let the professional taking off medication. Obviously, I'm a poll a patient out of there for away from the provider if a patient, if a provider refers to 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 that that to keep it simple, stay in your lane, like Kurvitt says, here to coust zero dollars to stay in your land. In mind your business, do what you're good at. Stick to the normal scale skeletal 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 game refer to you, But what about using your patient base as a referral source. I learned early on a practice we make the best normal scale 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 gotta watch this. I'm doing this at two o'clock today. Watch this, and I'm hoping he's gonna watch this, and I'm gonna say this knowing he's gonna watch it. When it comes to normal scale skeleton, 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 a northopedic surgeons a great surgeon, you you stick with them. All good, all good orthopedic surgeons will only do surgery when they think what they're gonna 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 time surgeries in an option. And that's why I say we're better nermal scale Skeleton because we're not just one trick ponies. We're not going to just cut somebody in 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 hundred lying problems without having a cut of patient. And that's what I mean. We're better than doctor balk if you're going to see this neuromuscular skeletal conditions. That being said, when it's surgical, the surgeon is going to get it. And that's what the surgeon wants to to see too. They want it when the conservatives failed, they want they want to know. When it's surgical, that's they're ready to roll. But we're not so great at other issues. Yes we're training cardiac issues, Yes we all took GIGU classes and all this stuff, but we're not great at them. So don't delve into them when you do your intake. When you talk to your patient, always ask about coromabilities. Are a diabetic hyd pretension? Always have them filled in the even though we don't do medicine and we may not know the medication. I have it when medicine are taking and what are you taking it for? Okay? So diabetes that can affect stuff, heart, cans that can affect normal scale scalpel, high coasterial can affect that staton. Drug use can all affect what we can 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 that how their health is going to affect the treatment and you're providing. Always ask if they have a primary care provider. Please do, I'll go through the medalist I have on my intake forms. Who's your primary care? More importantly for those comorbidities, if there's a condition there that's going to affect your treatment, over how they're going to respond to your treatment, and you want to make sure that's being actively co managed. Do you want to make sure that mister Smith who's a diabetic is getting regular checkup or his hypertensive, he's seeing his primary 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 at a regular basis, you know what three letter approach? Send them letters. Hey, you know what doctor Smith, mister Jones has been seeing me. He came from the low back man. Just want to keep you in the loop. 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 there's any issues that I can't handle, there's a problem for changes to reach out to you. Okay, three letters, initial, revolve final. They didn't refer the patient to you. But you're not using your patient base to make a relationship with a primary care that they may 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 mister Smith, I get his little back better, back pain better. He sees his primary In six months, primary goes through the final says, hey, you saw doctor Francis for your low back. How's that going. Oh, it's wonderful. It opens a door for that patient to sing your praises and to be like, he was wonderful. He managed my condition. I got better in the six visits. 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 gonna do now next time the little back pain after mister Smith, it's whoever the next patient is with low back pain. Hey, you know what, mister Smith, I just saw this. Patients said it was wonderful. Give them 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 priders I work with Orthopedic surgic referrals Hospital referrals and my pre existing patients. I said, 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 where I have an associate. Yes, but for the most part, my marketing budget is actually zero. And I between me and myself, I see about one hundred and fifty patient business a week. Can I see about twenty five to thirty patients a week at the origin care, I'm seeing now thirty patients every time I'm here. Hospitals about twenty twenty five. So I see patients. But I built my referral network based on using my patient base and using a referrals to 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 journey to use your network to get those primary care. So I one of my good friends, a piece of physicians assistant, he's been in my office. He see patients in my office. I work with them an urgent care works from at the hospital when they're hypertension and they have to say a primary care. In two years and a lot of people don't I use my MIC. 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 little back. You do the rest, and it builds that network. So by co managing with other providers, it's going to help facilitate helping your patients in a holistic way. You're not going to treat diabetes. You can help manage it, but their diabetes is now in check. Your patients are going to love you for it, and 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. Keeping in mind, your specialty is no muscular skeleton. Okay, that is your specialty. Stay in your specialty. Once it goes outside of that specialist box, you need to be referred. Primary care is not dealing with a fIF. Primary care is sending a fIF to cardiology. You should be in that same mentality. You refer patients when you need and 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 interests and their health is on the line here, you need to do it. That is what we should be doing for all our patients. Yes, we're great with MSK, but if they have IBS or they have prons disease that's being not managed. You're doing them a disservice by just dreaming a 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. I got lucky with the hospital I worked as a small hospital. It's considered a middle meetings hospital in Cleveland, and Cleveland's got the cleanmand clinic. So you want to make sure that the providers you're approaching, you need to understand most of them are institutionalized. And what I mean by that is they're usually affiliate 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 there 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 in a medical refral 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 gonna approach primary care down the street, you got to do some homework for that by understanding how they're structured. Also, you also understand how you can kind of facility and help complement what they're doing. So try providing providers and smaller hospital settings. There's not a lot of primary cares are independent still, but those are great providers to work with, okay, because they're not tied to hospital system. They're driven. And then understand there's always a risk if you send somebody somebody, Yeah, they might get stolen, they may not come back to you, and they may not to 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 patient 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 the 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 will 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 are with the school thirty forty 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. Ductor Purse, who I mentioned multiple times before. Ductor Purse graduated medical school back in the seventies. He's a general surgeon, you know what, but he's very open. He was very open to chiropractic. He loves our practical loves the right kind of fit. But he also knows there's some cairos out there that aren't necessarily evidence based, so you've got to kind of be aware. Usually your practitioners, recent graduates, they tend to have more well rounded understanding of what we do and those are typically easier people to approach. But again, understanding you do your homework when they graduated, what's their specialty? Are they hospital? Based on all that, So you really want to do your homework before approaching these providers. If you're listening to this podcast and you've yet to attend a Factor Rehab Live course, I have a special offer just for you. See, I realize that sometimes you need to kick the tires a bit to learn more about a course before you register, especially one that offers a certification track. So I've developed a special offer just for those of you who are interested in learning what this Factor thing is all about. See, We've put together a free one hour webinar to introduce the concept of having a systematic approach to rehab. In this one hour online course, our director of Education, Todd Riddle, will show you how implementing a system for patient treatment can improve patient outcomes, streamline your operations, grow your profitability, and help you to build a practice that you absolutely love. You'll also hear from doctor Riddle's personal experience in using the Factor Rehab system, both with elite athletes as well as the everyday patient just looking to move and feel their best It's a great first step to learn more about FACTOR certification and how FACTOR could impact your patient care. And to sweeten the deal, we're offering CE credit for completing this online training absolutely free. Yes you heard that correctly, free ce so CE credit is available in a number of US states for chiropractors, as well as for massage therapists, athletic trainers, and physical therapists. To learn more and get your free CE while learning more about how FACTOR can impact your patient care, visit the free Factor webinar link in our show notes. Now back to the show. All right, So, one of the questions I see is do you need a records release assigned in order to contact patients PCP due to hip up? So I always ask a 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 explained 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 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 another five months. I don't want you to have to remember, oh, yeah, by the way, back in May, I saw doctor Francis four times. I'll reach out to them nothing that we're doing, kind of approach them so that way next time you see them, they know what happened over the last few months. They don't have to remember that. And ninety nine point nine percent of actually one hundred percent of time, they're like, yeah, I should ahead and send a letter. You don't. As long as you have some kind of permission. You can have them signed like a little hipA compliant I'm going to release. But also remember you're not necessarily divulging any real health information, like you're hey, a low back pain, but you should definitely get some kind of consent from the patient. It doesn't have to be a full hippo release. 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 that's something definitely that week go. And 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. 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 it's one of my physicians assistants about 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 matter, depression matter, 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 apponent 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 pectitioner at the hospital that I work very closely with. She's part of an integrative health department and they do a lot of chronic pain and they have a psychologist psychiatrist they do the mental health aspects. So I'll kick it back to them. But I one hundred percent 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 like listen, I'll deal with the Moscow sclepel, 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 on my initial consultation, but 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. Like you've been in pain going on for so long. I tell this little like smart ass comment where I'll be like miss Smith, if I was in your shoes and I've been suffering with this for six months, a year, or two years, five years, whatever the case is, if you came into my office and you're all happy to go lucky and you thought this is the greatest day in the world, I would think there's something wrong with you like that. That's not normal what you're going through. I found in practice, you've had this going for so long. I think there's another aspect we have their address, Like 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 a cute stuff. I get to keep paying under control. But there's always a mental aspect to it, and you have to really gauge on our initial console 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 six visits because in my clinical experience, what I've done for these conditions has shown this kind of response. Now there's always complicated factors, but it doesn't go bat physical. There's also that mental aspect that as practitioners we have to be aware of. So definitely building that psychologist, psychiatrists, primary care mental health is incredibly imperative for what we do. And because early on a practice like I'd been doing these with patients and something at better and I'm doing the same thing and like this patient isn't getting better, and I felt like a terrible practitioner and it became frustrating for me. And then I realized I started doing the pain management part or understanding the psychology of pain, that psychosocial stuff. I'm like, wait, a sect, there's more than I can't help with that. I need to address and once I implemented that, especially with my chronic paint patients, and made a role the 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 is no right approach. A lot of it has to go with your comfort too. Is I'm an outgoing personality. I have a type of personality. My wife made the joke when I first met my wife's family was at a funeral, and like, I met all of them and I was, for lack of a better term, a life of a party. But it doesn't fit well for everybody, It really doesn't. So you have to find 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 every or three 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, doctor Francis, this is what I do for great things about or whatever the case is. But that's not 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 caller 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, bringing a box of candy, a muffins, panair or bread sandalis bread coming ready from the country. Do things like that to make the introduction. But again, go with your personality. You're like, I don't know how comfortable some people would be. Hey, I'm coming by your office. You've never been before. I want ten 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 which 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 him 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, nine of medical providers have no idea where their patients go. That usually the office staff approach, So dealing with the office manager, secretary medical assistance usually the best approach. So sending the letters a great way to get it going, and 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 it. 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 a hundred 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 ultimately can send the facts if you want to have done that. I still do that sometimes weird, but building slowly and just building on that relationship, so it goes off with it what it works for your personality. Again, most mds like they don't. Everything goes through their office manager. So you want to suite 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 MD work 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 cause a stroke. Those are my two favorite conversations to have. So my approach is always this, and it goes back to I don't want to counterpractic to me, isn't just manipulation? I do I manipulate all my patients? Yes? Maybe except for a few, but I pretty much manipulated some may sup from all my antients. But that's not just what I do. And it goes back to evidence page. So when they mentioned 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, your musculary education, dry needling, low quality evidence. Yes it might be a 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 we had, but building up cardiovascular stuff and managing all that you really want to just avoid. Chiropractic is just manipulation and that's not how I practice. It's funny because your athpedic surgeon that I work with, he's adodos are trained in manipulation. He doesn't manipulate, but he al sort of sees intrinsic value manipulation, but he also knows that's not That's one of the puzzle. So your approaches 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 exercise done. That's all they can do. I can go one step above it, 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 physicians stuff and it doesn't necessarily just have to be manipulation or heat or an acupuncture because I do evidence base, I do therapeutic exercise, I do trigger point massage, and I do airt and I do all the stuff. And to me, I don't avoid the question, kind of play it off as it may be low evidence, but it's worked for people, and I'm not going to know if it's worked for your patience. So we try it. So I try it on the patient. Doesn't work, then guess what. I'm not going to do it. I'm gonna do something else. And that's what they want to hear. And it's funny because the stroke talks and other talk. Well, I don't have to. I don't want to go into but it's one of those conversations that you have that's yeah, it might be a low evidence, but the evidence is constant, 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. Two out four alt five discriminations her needing the exact same way in two different patients. It's not going to respond to the exact same treatment in the exact same way. This is a trial and error thing. So I'm gonna try some of the low evidence stuff, sure, but I'm going to mix it with the high eveen and 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 Cairo that's gonna say, well, I'm gonna do this and this is this is my cookie cutter treatment plan. This is what's going to work, because they're gonna look at you and think, well, not everything works in 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 gonna know if it's gonna work for your patient while they try it. But I get a lot of the patients referred to me that I failed PT for a lot of my new 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 ev and stuff. Maybe that's gonna work. So there's different ways of dealing with that low evidence a pro which you just have to spin it to make sense to them. Absolutely, you've 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 going to give a shout of Greg to Greg Freedman. I've taken this class. I consider my friend. He taught me a lot about documentation. But the functional locome assessments to me, is the gold standard. I hear saying, I mean not even do a formal reevaluation on every patient two two one three, coding like, I mean I actually do that. My reevaluation may just be functional locome 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 FUNCTIONALCOME assessments had this rating. We notice a forty five percent decrease after six visits. That's language I understand when you can put a number on it. So for me, a FUNCTIONALCOME assessment is much more important rather than doing something like range emotion okay, so on visit one shit twenty degrees and range emotion inflection. But now she has thirty five providers gonna be like, that's fifteen degree. It doesn't seem like a lot. I mean that's a lot to us, But the primary I care that. They're like, what are you talking about? But now if we talk about functionally we know it's a forty five percent improvement in functional rating, They're like, oh, that's impressive. Like, so I'm a huge below and functional functionalcome assessments. And again I may not even do an 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 alcome assessment at visit five, six, seven 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 when I really care about your function, like how are you functioning? I need to know that when I first saw you could have been over retire your shoes, and four days later you're or four visits later you're bending over time your shoes, putting your shoes on. No pain or some pain. I never let pain dictate. And I have the conversation with my patients earlier, like I care about your pain, that's why you're here, but I really care about it us your function new pain scale. So I'll be like, if visit one year, six out of ten, but you can't do anything, but now you're a ten out of ten or an eight out of ten. But you know what you played with your grandson. You were able to play basketball, pay volleyball, go for a run. To me, that's a win and that's the way I'm going to approach that. So functional walcome assessments for you 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 forty five percent pcrease 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 income assessments huge in my practice, is huge. Or asking about ADL's mentioning case she can go work out at the gym without pain or whatever the case is. So you really want to mention function, I wouldn't necessarily use those raw numbers, but I would mention at thirty percent decrease in overall function 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 and they all know me. But early in practice I got that that happens, it happens. There's two approaches here that I kind of use on this. So it all depends on why the provider's joining it. So I'll always make a phone called by like, hey, doctor Smith, I refer to 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 logical in it and you can spin it with did I miss something? Was there a red flagon? And catch on them. Just want to make sure that what's your reasoning. There's two ansues 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 be high velocity on them. I think there's there's another issue. Or the response you're going to get as you're a quack and I don't believe what you do why, and that's what it is. Depending on the response. Again, if it's the quack comment, you're gonna have to chalk it up as a loss. There's no there's no trying to change in their mind, there's no beating in with information. There's no reason to get aggravated upset. It's not worth the battle. You're ninety nine percent of the time it's gonna be wasting energy and are going to change. They have that preconceived notion of 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 to the patient, I think there's an issue with that. Your typical approach should be listening. 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 gonna do some therapy. A actually is there's stuff we could do away from manipulation, like getting them mentality that because we're Cairos, 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 heard stories of It's funny because I had this conversation actually recently. Quick story. So I was working at the hospital. Doctor Purs referred to me a patient he did abdominal surgery on. He was in a low back and playing with ridicular complaints and he was like, do you wanted to trial a care before we do an MRI because he put in from MRI. The insurance company said, well, we need failed to conservative care before we do it. And so I did trial of care and I know it's ridicular. I was getting worse. I wasn't doing anything highve lossuit with him. I was doing some some soft tissue stuff. I was doing some activator, I was doing a little acupuncture. He was getting some relief with ridicular. Was getting worse. So I keeped it back to doctor Purse, who's a general surgeon. Like listening to him, 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 it's like, okay, we'll go ahead and we meet. We co admitted him, We admited him to the hospital. He saw one of the neurosurgeons who's good friends with doctor Purse, and he ends up doing a DISKCT to me and decompression the very next day because it was getting bad and the ridicular was getting bad. And as he's walking out of the hospital, he stopped in my office to the hospital, he cames like, hey, then the surgery. I'm like, I heard whatever, so I didn't come visit you during surgery or post stop. I was a lot 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 gonna anything crazy. I'm gonna he had I think it was all four, all five or all five of us one, and I'm like, I can do some accupunctures, manage some of the post stop pain. We can do a little ice. We knew some interferential We're not gonna do anything too active, too crazy, too soon, but we can at least help postopera. We get the pain. So we follow up to me a couple of days later, once he got settled and whatever. And it's funny because it was all four all five. I did activator on him, like mid thorastic, maybe throackle, lumbar junction and maybe the side joint. And then I did act unent for postop pain. And I did a little passive with him. I did nothing active with him. 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 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 I'm not high velocity. I'm not side passing this personal I'm cranking. I'm not doing anything stupid. I'm managine postop pain and I'm manipulating like well above it and well below it to keep motion going. And I wasn't phased by that. I deal with all time. Well, you're a kind of if you manipulated 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 seeing me, I respect that, no problem, and I go. But you need to realize I admitted the patient with doctor purs Like, we co admitted this. I know what's going on. We're the reason the surgery had Like where the reason the surgery happened? Yes, you did the surgery. And it was funny because I got off the phone and I walked my back office and doctor Purson's back there, like what's going on? And I told him, Michael, I'm not upset with it. I understand, but I'm kind of offended that they told the patient about 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 clinical was over. He's on this patient. He actually got a patient office. He went upstairs the surgical before I found the surgeon and literally he was a friend of him for twenty years. Told him, don't ffort with doctor Francis. He's not stupid. You need to call him and apologize he was doctor Purst was more aggravated that that happened than I was. It's part of what it is and you have to not see it, and I took none of a 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 clinical you show that you can, you're not just manipulating a dangerous partner. It's funny because three weeks later guests who referred to me a patient the neurosurgeon. Okay, so it's not 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 go will fight for you, and then you don't have to fight that battle. You I got great hair and I'm barely forty 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 want to work with you. And if they don't, that's their loss and their patient's loss. If they want to prescribe them and do whatever, that's fine. You have to understand that you can't be combated, 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 patience 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 your concerned manipulation because of X, Y, and Z, but that's not what's just what we do. I'm going to provide positional level services. I'm going to monitor them, undo therapetic exercise. I'm going to make sure what we do is evidence based and safe, and that can go one of two ways. Either gonna be like, okay, they can see you again and nine times out of tendant 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 so just understand that's what risk you might have to take. But it surprisingly doesn't happen as much as you think. When you ask that as extra question, make that phone call and try to communicate it usually usually results pretty quickly without losing the patient. 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 two on in the future because there's so much to unpack it. There's so much going on here. Yes, I mean, be sure to tune in for episode fifty seven, where we'd kick off a new training title, Creating an Effective Prehabilitation Program with doctor Davis McAlister. In this two 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 discussed the application of force and movement as it relates to injury prevention. You won't want to miss it. Episode fifty seven drops in two 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. 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 five 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 surveys, 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 to click on the Factor survey link, or visit our linkin 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 hyphenstore dot com that's spelled fak tr hyphenstore dot 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,