GPs Referring Another Client to their Chiropractor?
by Dr Paul Bergamo

Does this sound ludicrous? Lets explore the process….

GPs, like chiropractors, have primary contact responsibility and are gatekeepers to clients as a first port of call. Lets examine the first onset back pain client who has never seen a chiropractor before. In this case, unfortunately (outside a family or friend recommendation) bread and butter cases we see daily would first end up in the GP’s office.

Thus we have a problem. Unless coming from a personal referral, thousands of clients would still see a GP before the chiropractor for back-related conditions.

Then what? Pharmacology would be prescribed if the GP wanted to manage the case alone. Otherwise, their preferred physiotherapist would be referred directly to.

I think most of us who work with GPs understand this model.

How do we break the cycle? Some ideas…

1. Psychology
   Despite the paradigm differences, the common element is the client. The simple aim of putting the client first should overcome any other barrier to communication. After meeting with GPs, one maybe surprised at a sense of similarity. Moving away philosophical differences, we are two health providers who have similar challenges - a results based consumer, issues with third party payers, challenges with staff and running a small business. There is no doubt the core success to developing a link with a GP is to develop a professional relationship. The GP’s principal fear is to trust whom they are referring to - are they competent, caring and actually going to improve the health index of the client? Mind you that represents another similarity between both professions. If you have to refer out, don’t we have these similar criterion to ensure out clients are well looked after?

2. Clinical Reasoning
   The clinical challenge brings with it dilemma. There is a need, on occasion, for a second opinion. This process is easier if open dialogue comes with a GP. This is especially critical in the differential diagnosis stage of establishing what is going wrong or if our management is not going to plan. Imagine a situation where unsure about the diagnosis or management plan, a call to the GP results in constructive soundboard discussion. This can happen and more likely if one has a working relationship with the GP.

3. Use of Complimentary Medicine
   The use of complimentary medicine is expanding in Australia. In 2000, it was estimated that about 50% of the Australian population took a natural supplement and about 20% formally saw a complimentary medicine practitioner (MacLennan, 2002). In light of this, there is an increase in chiropractors housing a small dispensary in their centre. Lesley Braun (pharmacist, naturopath, herbalist and co -author of Herbs & Natural Supplements, an evidence based guide, Elsevier, 2004) is completing her PhD on knowledge of complimentary medicine in Victorian hospitals. Some of her preliminary data reveal that clients don’t converse freely about any CAM or therapy within the hospital framework (Braun, 2004). One would be confident that we could extend this concept to primary practice. The advent of drug - nutrient interaction will be a new era of health complications that will develop impetus in the next decade. Inhibition and potentiation of drugs and supplements often occur when they are taken concurrently. As chiropractors, we need a sense of knowledge of this and often would need to communicate with a pharmacist or GP, sometimes, before we decide to advise on natural supplements.

4. The Allied Health Item
   Since July 1 2004 this new government initiative has brought different reactions among out profession. Some will say no change and others who understand the care plan set up and have a relationship with a GP are using it well. To be eligible, a client must have a complex and chronic (> 6 months) health condition to be placed on a enhanced primary care plan. In the chiropractic world, this would fall under two major banners of chronic back pain and chronic cervicogenic headaches. From the GP perspective, the barrier is inclination to complete care plans in the first place. From my meetings with GPs, it appears single doctor clinics with less staff resources, view care plans as too much paperwork. Multi - doctor clinics with office mangers are more likely to have better resources to set up care plans. As mentioned by my co-presenter at the last COCA talk - Dr King Gan - care plans requires two weeks preparation time to complete i.e. ensure the logistical challenge of having client and health providers all onboard. For more details and/or to download the Referral form for allied health services call HIC on 1800 067 307 or download from HIC website at www.hic.gov.au/providers/forms.

In conclusion, the health landscape is changing. In the last decade, thanks due, in large, to clients speaking with their feet, Chiropractic has been included in extras coverage of more health funds. The government understands the drain on the health budget chronic pain plays and in a way, are encouraging multi-disciplinary management with the advent of the allied health item. Perhaps the public perception that Chiropractic and General Practitioners are complete adversaries needs some review. The system is not perfect and there will always be those from both parties who refuse to communicate. However, this scenario represents a personal bias. For change to occur, there must be a willingness and a reason. Is optimal client management not a high enough health driver of why doors of communication need to be opened?

MacLennan AWD, Taylor A. The escalating cost and prevalence of alternative medicine. Preventative Medicine 2002; 35(2):166-73.
Braun, L Personal Communication, 2004.