1

22 Windridge Lane,
Temple Georgia,

Approaching PCs As A
Spine Specialist
VOICE
Executive Summary
Prepared By
Integrative Care Associates, PC

Prepared For
Fresno Pain Care Specialists
Fresno Imaging
Fresno Cardiology Group
Guerrilla Marketing Strategies
For Establishing Multidisciplinary Collaboration
2
All forms, letters, concepts, scripts, approaches are Copyrighted and Patent Pending
Intellectual Property for the sole use of VO Licensees. VO protects it’s licensee’s
exclusive rights to these materials. A hefty sign up and annual renewal fee is
charged to our licensees for the promotion and protection of our property. Any theft
and unauthorized used by a non -icensee is strictly prohibited.

Safe Harbor laws were considered and applied in the creation of these materials.
Prior to the use of these materials, however, each licensee is required to obtain legal
opinion from their counsel, and provide proof of authorization and
recommendation for the legality of these forms. The documentation of the
licensees consultations with their legal counsel, accountants, and licensing
agencies governing the enforcement of safe harbor laws, are essential before the use of
any materials in this summary.

All licensees must seek counsel and ensure that the use of these materials is within all
Federal, State, and County health laws for the diagnosis, treatment or care, and
when insurance or Medicare is billed, that the forms used are subject to
reimbursement under all applicable laws, regulations, rules and protocols.

In regard to any techniques, systems, approaches or methods suggested herein, no

action should be taken prior to consulting with an attorney and/or a professional
consultant to ensure that such activity will comply with all applicable state and federal
requirements and limitations, including, but not limited to, anti-kickback, fee splitting
and self-referral laws, reimbursement requirements and limits, truth-in-lending
disclosure requirements and usury laws.

Federal State and County Laws, vary from one place to another in their
rules and regulations. The material assembled herein, may or may not
be authorized for use in your case. It is your responsibility to seek
counsel, and to comply with all laws and codes of ethic. These
materials are copyrighted, and no authorization or permission is
granted to copy the the content herein just by virtue of your coming
into possession of this document. Unless you are authorized
3
licensee, you will be prosecuted the fullest extent of Copyright and
Healthcare laws.

Integrative Care Associates, PC

Fresno Pain Care Specialists

Guerrilla Marketing Strategies

The letters contained in this executive summary were created by obtaining

actual copies of letters, with authorization to reproduce, via payment of fees, for
inclusion in this executive summary. The summary provides 26
Subspecialty letters for multidisciplinary collaborative care and one letter to
Primary Care for Rehabilitative Physical as well as one for Cardiovascular
Endothelial Dysfunction medical necessity referral letter. Template is the same, with
customization for each Spine Care Specialist as well as each PC from whom referral
is being requested. All PCs have received a letter from our Referring Radiologist and
for Endothelial Function Screen Group. Each Patient is assigned a Sub
specialist for the Visceral Diseases that may have a cause effect relationship with the
Somatic Dysfunction being treated. All musculoskeletal care is evidence based and
licensees are required to consult a Radiologist or Cardiologist, based on
VOEndoScan. The Algorithms and Evidence Based Referral Generating Letters in
the Software are proven and tested to create a dialogue between you and your present
and future Patient’s PC or Sub specialist designed to give you methodical procedures
for building a referral practice through the medical profession. Although these
procedures will be very effective for all disciplines of health care, our main emphasis
will be on medical doctors in primary practice.

The MD DC Model GAME

It makes me puke to see the material I receive from

leading credible MD DC consultants who each have an
amazing sales system of teaching MDs how to attract
patients for Chiropractic care. The pages are slicker than a
Nude Picture of J LO. The scripts, better than anything
Rainbow can ever come up with to sell their $2500
4
Cleaning system. Yes, the DCs have done almost as good a
job if not better to attempt to attract the MDs. But if you
believe it is the lack of slick Landing Pages, Email Letters, telephone scripts, or even
hosting the radiology luncheons, as a DC – you are missing it. It is the inability to
communicate with the MDs of your own patients, and thinking like MDs think,
about disease detetction, treatment and moniotoring and documenting pre and post
findings, that Innately excludes you as their choice between DCs or PTs or drugs.

It is the purpose of the authors, MDs DCs DPTs who understand this and share
acceptance and collaborate with each other – what today’s patients demand, patient
centered, evidence based, preventive care.

It is the Neuroscience of Palpatory findings, the correction of the false

teachings of Keating, Homola, Seaman and similar Straw Men, promoting and
winning at attracting followers of their “Straw Men Fallacies” and the profession
inability to overcome their opposition. Ironically, both problems have the same
solution. It is the lack of inclusion, in exams, re-exams and ROFs as well as MD DC
communication, of the inclusion of such Objective Neuroscientific,
Neurophysiological and Biomechanical markers, that have scientifically proven and
accepted links of Somatic Dysfunction to Visceral Disease. It matters not, if it is
considered mimickry by the Straw Men. It matters that the presence is eliminated.
And if palpatory findings due to the inflammation of the fascia and the endothelial
cell, resulting dysfunction, aids in the diagnosis, and correcting the biomechanical
abnormalities ( a k a Spinal Lesion, Vertebral Subluxation, Joint Dysfunction –
collectively Manipulable Lesion) – aids in correcting what the Straw Men call
mimickry and true scientists, neurophysiologists call viscerosomatic disorders. both
somatically and viscerally. l accepted promoters of the
chiropractic profession. I just recently viewed a Rainbow
cleaning system – and in the presentation the sales rep
ripped every other vacuum cleaner, and what it does
wrong. Of course. Rainbow had every bit of it right.
However, all I remember is what awful unhealthy
unsanitary Sanitation job all other vacuum cleaners do, but
I remember very little about the Rainbow. So the current
promoters of the MD DC Model would make excellent
Rainbow Cleaning Systems. Just as Rainbow is not a
Vacuum cleaner but a cleaning system, neither is
Chiropractic a Disease Vacuum cleaning system but a true
5
Healthcare System, unlike the Allopathic Model of Sick
care, falsely advertised as healthcare. Now with our
EndotHEALium Total Healthcare Integrative Care System.
(Medical E.T.H.I.C.S. Medical ETHICS Group., AnalysPlus
Scan Model, OMG what a joke. MDs don’t collaborate based on a
marketing campaign, but on the indications or contraindications of drugs, surgeries
or healthcare differential diagnosis algorithm

Certainly the same steps will work for the various medical specialists and they
should be contacted. However, we believe that the first step in creating this network
should be directed toward the general practitioner.

In the past, chiropractic offices have spent up to 10% of their services rendered
in advertising. In today’s market, advertising per se is becoming less effective. We
encourage converting the use of a certain portion of your advertising dollars into
public relations and promotional events, such as those discussed in this project, the
HMO/PPO project, and other public relations projects to be distributed by VA CAM
Center in the future. It may become necessary to dedicate a part-time or full-time
staff person
strictly to the administration of these public relations projects. We believe it is a
positive step in practice growth.

6
 CREATING AN
INTERDISCIPLINARY
REFERRAL NETWORK

With the changes that are taking place in health care, VA CAM Center believes
that one of the most important steps for the chiropractor to take toward building the
practice for the future is to create an interdisciplinary referral network. We need to
build, and in some cases rebuild, the bridges between the chiropractic profession and
the medical profession. The reason there is an old saying that you’re not supposed to
burn your bridges behind you is that it takes longer to rebuild the bridge. The
procedures
mapped out in this booklet will not make it possible to have medical referrals with
the first phone call, letter, or activity that you do; they will not be instant practice
builders for the first month; but, they will be consistent practice builders that will be
essential investments in the future of your practice. We are confident that if you
follow the
steps recommended herein, you will find consistent growth in your practice and
community awareness.

7
 Primary Care Physicians CD – The CD Contains all PC MDs

You will need to compile a list of all doctors in the medical profession who
have the potential to refer patients to your clinic or vice versa. Here are some
suggested steps toward compiling this list:

1) Make a list of the MDs that your current patient base utilizes as primary
doctors. Be sure that your health history form has a blank asking for the name
of the patient’s general practitioner. You will use this information to send
patient-update letters, as well as to know the MDs in your area having patients
also utilizing chiropractic.

2) Every patient you have sees an MD, OB-Gyn, Pediatrician (RA Neck
Pain) and the Patient’s PC Letter is sent to all the MDs in your area,
quarterly Pain Report – sent three times per year, for quarterly
luncheons hosted by Radiologist or Cardiologist Endothelial
Health Report (Human Body Image)

3) If you are in a city, limit your list of MDs to within a 5- to 10- mile radius
of your office (or other reasonable distance for your locale). There are a lot of
MDs, and your list would become quite long with names of MDs that do not
have the potential of referring patients a far distance from their practice. If you
are practicing in a small town, this list would include all MDs that have
the potential of referring to your clinic. Some of them may be 15 or 20 miles
away.

4) You will need to separate your list into specialties and limit your work to those
having the highest potential to mutually refer. If the list is small, you will be
able to create your referral network for all disciplines on the same list.

5) When you are categorizing your list by specialties begin with your list of
primary providers, which will include general practitioners, family
practitioners, internists, and pediatricians. As you study this list, you may want
to divide it into categories of highest potential and those who would not be
worth the time or effort. Be careful not be too judgmental with
these doctors. If there is any question, do not eliminate them
from the list. Opinions can be changed. With the proper education and the
8
changes taking place in health care, it’s very possible that some doctors who
have been very negative toward chiropractic will change in the years ahead.
We would prefer that you not eliminate any MDs from your list rather than to
eliminate so many that your list now consists of one or two names.

9
6) If you are practicing in a city, the entire list of MDs can be obtained from
a mailing company. They can also break down the list into zip codes,
convert them into labels, and label your correspondence at your request.
In other words, it is possible for them to compile the list for you if you
prefer not to assemble your own list. However, your list will probably be
small enough to manage by yourself.

1
 LETTER OF INTRODUCTION

One thing is certain: an MD cannot refer a patient to you if they do not know
you exist. It is important that they not only get to know chiropractic, they must also
get to know you. The first step toward gaining the MD referrals is to gain exposure
through a letter of introduction. The following page will give you a sample letter of
introduction that you can send to the medical professionals in your area. There are
times when it may be appropriate to have a paragraph thanking them for their referral
and then many other times this may be a “cold” letter. Format the different types of
letters you will need and then instruct your staff on how you want them to be
implemented.

1
[Date)

, M.D.

Dear Dr. :

Over the last few months, I have become increasingly involved in helping
several your city/town 1-area physicians in the management and care of their patients
suffering from back pain = PTSD. Although we have never had the
opportunity to work together, I realize that this is largely due to the fact that you have
never had the opportunity to get to know me and perhaps you have never had the
opportunity to get to know chiropractic. I would like to eliminate both of these
obstacles and establish a friendly, professional working relationship with you.

To briefly let you know who I am, I came to [ your city/town ] Fwhen?]
[provide brief - and I mean brief biography highlighting your educational
and residency background degrees awards]

In the process of staying current in your own field, it is difficult to remain

abreast of developments in other areas.

A special article in The Journal of Family Practice reports that in a

study of health management organizations (HMO) and non-HMO settings, 50% of
family physicians surveyed believed they were only slightly, or not at all,
informed about the clinical scope and skills of chiropractors, although 26% saw
them as an excellent source of care for certain musculoskeletal problems.

The latter group tended to be the younger family physicians who were also the
most knowledgeable about chiropractors and more likely to have encouraged patients
to see them. Chiropractic is playing an increasing role in the primary care of
musculoskeletal problems and family physicians should reevaluate their relationship
with these health care providers. As recent as ten years ago the basis for chiropractic
was not scientifically understood. There is now extensive research and data gathered
by primarily medically oriented institutions directed at this. The mechanism for
1
 13

Dr.
Date
Page Two

manipulation is now clearly validated and understood. Manipulation has been shown
to be three times more effective than up-to-now accepted outpatient procedures for
non-surgical patients suffering with back and neck pain. It is interesting to note that
presently over 80% of family practitioners and internists in several European
countries, Switzerland for example, are now manipulating their patients. It is also
interesting that manipulative therapy has become a regular course and clinical rotation
in many of the more progressive foreign medical schools. This acceptance of the latest
information and knowledge is making inroads into our country.

I have included with this letter a [see list of enclosures on page 10] or)
a recent article by Arthur H. White, M.D. in a recent issue of JMPT.

In the course of conversations with other medical doctors, they have expressed to me
their particular frustration which can accompany management of non-surgical back
pain patients who do not respond to medication. The majority of my practice is
comprised primarily of this category of patient which can be so frustrating to manage.
What I would like to offer you is help and assistance in handling patients who present
in this way. It is my desire to provide you with a solution to this problem. By offering
qualified, ethical, manipulative care that you can be confident in, those patients can
receive a much needed conservative alternative.

I would sincerely welcome the opportunity to discuss this further at your convenience.
I will be calling you in the very near future to see if this can be arranged. If I can be of
any assistance, please do not hesitate to contact me.

Sincerely,

Bundle O. Bones
D.C.

Enc.
1
 SAMPLE LETTER
July 9, 1996

Bruce Rodan, M.D.

648 US Highway 1
North Palm Beach,
FL 33410

Dear Dr. Rodan:

Over the last few months, I have become increasingly involved in helping
several Palm Beach physicians in the management and care of their patients suffering
from back pain. Although we have never had the opportunity to work together, I
realize that this is largely due to the fact that you have never had the opportunity to get
to know me and perhaps you have never had the opportunity to get to know
chiropractic. I would like to eliminate both of these obstacles and establish a friendly
and professional working relationship with you.

In the process of staying current in your own field it is difficult to remain

abreast of developments in other areas. (A special article in The Journal of Family
Practice reports that in a study of health management organization (HMO) and non-
HMO settings, 50% of family physicians surveyed believed they were only slightly or
not at all informed about the clinical scope and skills of chiropractors, although 26%
saw them as an excellent source of care for certain musculoskeletal problems.) The
latter group tended to be the younger family, physicians who were also the most
knowledgeable about chiropractors and more likely to have encouraged patients to see
them. Chiropractic is playing an increasing role in the primary care of musculoskeletal
problems and family physicians should reevaluate their relationship with these health
care providers. While it is true that as recent as ten years ago, the basis for chiropractic
was not scientifically understood. There is now extensive research and data gathered
by primarily medically oriented institutions directed at this. The mechanism for
manipulation is now clearly validated and understood. Manipulations have been shown
to be three times more effective than up-to-now accepted

1
Dr. Bruce Rodan
July 9, 1996
Page Two

outpatient procedures for non-surgical patients suffering with back and neck pain. It is
interesting to note that at the present over 80% of family practitioners and internists in
several European countries, Switzerland for example, are now manipulating their
patients. It is also interesting that manipulative therapy has become a regular course
and clinical rotation in many of the more progressive foreign medical schools. This
acceptance of the latest information and knowledge is making inroads into our
country.

I have included with this letter a short but educational brochure on the scientific
findings of chiropractic that will make it quick and easy for you to stay current on our
treatment of lower back pain. I would also like to invite you to visit our clinic to see
for yourself how patients are treated.

In the course of conversations with other medical doctors, they have expressed
to me their particular frustration which can accompany management of the
non-surgical back pain patient who does not respond to medication. The majority of
my practice is comprised primarily of this category of patient which can be so
frustrating to manage. What I would like to offer you is help and assistance in
handling patients who present in this way. It is my desire to provide you with a
solution to this problem. By offering qualified, ethical, manipulative care that you can
be confident in, those patients can receive a much needed conservative alternative.

I would sincerely welcome the opportunity to discuss this with you further at
your convenience. I will be calling you in the very near future to see if this can be
arranged. If I can be of any assistance, please do not hesitate to contact me.

Sincerely,

Bundle 0. Bones, D.C.

En c.
16
 POSSIBLE ENCLOSURES WITH
LETTER OF INTRODUCTION

We recommend any of three possible enclosures to go with your letter of introduction.

It would be too much to send all three enclosures in one letter, but you may choose to
obtain all three and send them with different follow-up letters.

Enclosure No 1 Article by Arthur H. White, M.D. JMPT.

Enclosure No.2 The Journal of Family Practice, Nov. 1992, Vol. 35, No. 5,
pages
551-555. Reprints can be ordered from The Journal of Family
Practice by phoning (203) 838-4400, and are priced in quantities
as follows: 100-8337.50; 200-8405.00; 300-8472.50; 400-8540.00;
500-8607.50.
Enclosure No.3 “Studies on Chiropractic” by the National Board of Chiropractic
Examiners: a summary of published studies and official inquiries
documenting the efficacy and appropriateness of chiropractic
health care. Reprints can be ordered from The Foundation for
Chiropractic Education and Research by phoning (303) 356-9100,
and are priced in quantities as follows: 100/ea. - $12.00 (free
shipping for quantities over 500).

Samples of these three enclosures are found on the following pages and inside
the back cover.

**** NEED NEWER ENCLOSURES

1
 Integration of Chiropractic into Managed Care in a Multidisicplinary Setting

Arthur H. White, M.D.*

ABSTRACT
The first round of managed care flour- ished from 1990-1995. As the
“economic screws” tightened, all subspecialties of health care lost their unbridled freedom to the
primary- care physician. Patients can no longer visit their subspecialists (including chiropractors of
choice. As the public becomes disenchanted with such limited managed care and as new
re- forms of managed care emerge, the chiroprac- tor and other subspecialists are regaining their
rightful position.
Centers of excellence can clearly diag- nose and treat a patient more quickly,
economi- cally and accurately than the bureaucratic “kicked back” primary care gatekeeper.
Enlight- ened managed care business developers are using chiropractors as primary care health
pro- viders and are using centers of excellence that include chiropractors as a major cog in
the wheel. The new managed care system directs patients to
the least expensive professional who can get the job done most efficiently and accurately. With minimal redirection, the
chiropractor is the ideal professional to diagnose and treat the early phases of spinal problems and can easily triage patients
to the most appropriate chronic healthcare providers. (J Manipulative Physical Ther. 1995: 1S:526-7)
Key Indexing Terms: Chiropractic, Managed Care, Health Services Accessibility.

1
I * Medical Director, conditions or when
N r San Francisco Spine patients became
T Institute, and private frustrated and de-
R y manded to be referred.
Managed care practice medicine, San The medical doctors and
O before 1990 was Francisco, CA. Submit
D limited to such or- advi- sors of these
reprint request to: managed care
U ganizations as Kaiser
Permanence and a few Arthur H. White, organizations were rarely
C
other large clinics and M.D., Spine Care chi- ropractors and rarely
T
understood the value of
I medical groups. Medical Group, 1850 chiropratic.
O Chiropractors were Sullivan Ave., Suite
rarely included in such As managed care
N 200, Daly City, CA organizations rapidly
large health care
provided organizations. 94015 grew, from covering 5%
Managed care is of the population to as
rapidly changing in the In most areas of the Pap
country, managed care er much as 50% of the
20th cen- tury. We all population in many areas
tried to prepare for the accounted for less that sub
5% of the public and of the United States,
21st century. There are mitt there was great
some definitive trends therefore had little ed
effect on chiropractors competition for
that can allow the Apri providing less and less
chiroprac- tor to play a or other health care
providers. Patients were l 17, expensive healthcare.
pivotal role in managed The quality of care and
care in the future. allowed, through their 199
referral to the
medical insurance, to 5.
see any practitioner of subspecialist (including
D the chiropractor)
any specialty.
As managed care plummeted. Many
I subspecialists were
burgeoned in the
first half of the driven out of practice
S or moved to areas less
1990s, primary-care
physicians became heavily involved with
C managed care.
“gatekeepers.” In many
U cases, these
“gatekeepers” were C
remunerated for u
S r
conserving on care.
Referrals to any r
S
subspecialist, including e
I chiropractors, was n
viewed negatively by t
O the business overseers
of the managed care S
N organization. Quality of t
care therefore dropped. a
The primary-care phy- t
sician was not qualified u
H to manage all aspects of s
all dis- orders. Rarely
i was the primary-care The older,
physician even established managed
s knowledgeable enough care organizations, such
to know when to refer as Kaiser Permanente,
t to a subspecialist. have taken great losses
Referrals occurred only in membership because
o under emergency of the newly developing
managed care
1
organizations. Patients
have become
disenchanted with both
old and new managed
care organizations be-
cause of their limited
ability to access medical
care of the quality to
which they had
previously been accus-
tomed. Managed care
organization are joining
together to become
huge, unmanageable
conglomerates that are
unable to monitor quality
of care or the cost of
healthcare. As some of
the organizations attempt
to compete in the
marketplace, they reduce
the quality and numbers
of their subspecialists.
The subspecialists who
are contracted have to
accept contracts for
reduced fees as low as
50-
60% of their customary
fee. Many practitioners
who have not had the
ability to monitor
contracts and track pay-
ments have found their
income to be reduced by
as much as 40%. This
has driven many
practitioners out of the
marketplace.
Practitioners are having
to band together to
better negotiate
contracts and track
payments. This turmoil
and confusion is
sweeping the country.
Some areas have not yet
been stuck but the trend
is inevitable.

2
 With public dissatisfaction and foresight by some
businessmen in managed care, the downward spiral
of quality and efficiency is beginning to turn around.
Man- aged care organizations are arising that have
quality or care as their primary concern rather than
the provision of the least expensive care. It turns out
that high-quality care is actually less expensive than
trying to blockade patients from care.
For example, a patient with a medical condition
who is blockaded by a primary-care physician may get
worse because of the procrastination, may get worse
because of frustration, may be unable to work, may
lose produc- tivity and may even sue the managed care
organization because of catastrophic occurrence
attributable to the procrastination. If such a patient
has been retired to a subspecialist who was well-
schooled in economy and efficiency, the patient
would get well more quickly with less consternation
and be happier with the providers of care.
These new managed care organizations, therefore,
are using triage organizations to get patients to the
most appropriate level of care as rapidly as possible.
The chi- ropractor is a very appropriate triage
individual and also a very appropriate subspecialist for
early referral for man conditions
THE Future
Chiropractors must learn and live by the same
algo- rithms, time frames and economic efficiencies as
all other healthcare providers. Those working by such
guidelines will be quickly recognized in any
community as the subspecialist of choice.
Chiropractors who want to become primary-care
providers will be invited to do so by the new, more
en-
lightened managed care organization. The Chiropractor
will be tracked by the managed care organization just
as any other health care provider is tracked. Those who
prac- tice most efficiently and successfully will remain
in the game. Those who insist on using old methods of
treat- ment and clinging to old belief systems will not
survive the 21st century. The new managed care
organizations will use the guidelines produced by the
Agency for Health Care Policy Reform (AHCPR),
which acknowledge the value of manipulation in the
acute phases of back pain. There are few, if any,
acknowledged modalities for the acute phases of back
pain. Therefore, the chiropractor is in an ideal position
to be the primary manager of acute spinalproblems.
The new managed care organizations are already
looking for inexpensive ways to screen and treat acute
spinal problems. They may turn to nurses or physical
therapists. The chiropractor is certainly in a better posi-
tion than is the M.D.
The centers of excellence for spinal problems will
be multidisciplinary groups. They too will be looking
for the least inexpensive problems. The chiropractor
again is in an ideal position to be part of these
multidisciplinary groups. Some of these groups will be
developed and run by chiropractors who will not only
be the primary care giver, but will also function as
diag- nostician, therapist, educater and
communicater. The chiropractor will make the
decision for diagnostic test- ing, surgery, work status
and disability.
CONCLUSION
It is time for the chiropractor to expand his tools an
take more responsibility for the whole patient and how
to function in our society.
2
SPECIAL ARTICLE

Family Physicians, Chiropractors, and

Back Pain
Peter Curtis, MD and Geoffrey Bove, DC
Chapel Hill, North Carolina
In this article, major aspects of back care provided to patients by family physicians and chiropractos are
reviewed,and the recent guidelines on spinal manipulation therapy are discussed. These guidelines should be
useful for family physicians wishing to refer patients to chiropractors.
Key words: Chiropractic; backache; physicians, family; referral and consultation. J Fam Pract
1992;35;551-555.
In a commentary on back pain The Journal of Family
Practice in 1988, Dan Cherkin wondered why there
had

2
been so little study of this problem by family
physicians, and whether this was attributable to their
satisfaction with current approaches to care or to
frustration over their inability to modify the course of
the illness. In this coun- try, low back pain,
dysfunction, and work disability are moving toward
epidemic proportions, and the contest in which back
problems occur most often results in pre- sentation to
primary care physicians, particularly family
physicians. However, another discipline, chiropratic,
is playing an increasing role in the primary care of
muscu- loskeletal problems. Family physicians should
therefore reevaluate their relationship with these health
care pro- viders.
Manpower Issues
Back pain is the second leading reason reported by pa-
tients for visiting physicians. Every year nearly 13 mil-
lion visits are made to physicians for chronic low
back pain, and it is the second leading cause of work
days lost. From 1971 to 1981, the number of disabled
people and the costs of care for low back pain
increased at a rate 14 times that of the population
growth. In the medi- cal settings, family physicians
care for 38.6% of the pa- tients with acute and chronic
back pain, compared with
36.9% seen by orthopedics, 16.9% by osteopaths, and
7.6% by internists. Back symptoms are the third most
common reason for visiting a family physician.
Submitted, revised, May 5, 1992.
From the Department of Family Medicine
(P.C.) and Cell Biology and Anatomy (B.B.),
University of North Carolina, Chapel Hill.
Requests for reprints
should be addressed to Peter Curtis,
M.D. Department of Family Medicine, CB
#7595, School of Medicine, University of
North Carolina, Chapel Hill, NC 27514
1992 Appleton & Lange ISSN 0094-3509
The Journal of Family Practice, Vol. 35, No. 5, 1992
Chiropractors account for about twice the number
of visits for back pain as physicians. In an 8-year com-
munity based survey of six sites in different parts of
the country. Skellee and Brook reported that 7.5% of
the population made at least one visit to a chiropractor;
42.1% of the visits were for back problems and 10.3%
for neck problems. Manipulation accounted for 66%
of repeat visits.
Thus, in terms of musculoskeletal problems, family
physicians and chiropractors provide the majority of
ambulatory care in the health care system. They tend to
serve similar populations and yet their services do not
seem to be in competition with each other. Certainly
both groups have grown in numbers over the past 20
years. There are at least 20,000 registered chiropractors
in the United States who treat over 7.5 million people
each year with services covered by Medicaid,
Medicare, and gov-
ernment-employee and private insurance, as well as
state worker’s compensation.
Perspective on Back Care
In a series of reports based on physician,
chiroprac- tor, and patient surveys, Cherkin and
colleagues offered some interesting insights on the
management of back pain by these professionals. In a
study of health man- agement organization (HMO)
and non-HMO settings,
50% of family physicians surveyed believed they were
only slightly or not at all informed about the clinical
scope and skills of chiropractors, although 16% saw
them as an excellent source of care for certain
musculoskeletal problems. The later group tended to be
the younger fam- ily physician who were also the
most knowledgeable about chiropractors, and more
likely to have encouraged patients to see them.
551
2
Chiropractors and Back Pain Curtis and Bove

2
 increase physician comfort and confidence in managing
Patients perspectives from another well-designed back pain. Although an increased feeling was noted on
study restricted to an HMO population indicated the part of the physicians that their patients were more
signifi- cantly greater satisfaction with chiropractor satisfied and reassured about their problem, a survey
care than with family physician care. Items of back of the patients
care provided by family physicians with which
patients were not very satisfied were: information
about the cause of pain; ad- vice on recovery time and
how to manage the problem; and instruction on
posture, exercise, and lifting skills.
Patients believed that family physicians were less
confident and comfortable in their diagnosis and man-
agement and showed less concern and understanding
of their problem than chiropractors.
The number of days of disability for patients seen
by family physicians were significantly higher
(mean
39.7) than for patients managed by chiropractors
(mean
10.8).
What were the chiropractors doing right and what
were the family physicians doing wrong? Although
not based on randomized controlled
interventions,these data suggest that family physicians
were not able to provide as clear or rational an
explanatory model of the problem to the patient as the
chiropractors. In addition, they did not individualize
management well. These issues, as well as the possible
value of hands-on-manual therapy, could be
addressed by additional training and education in
musculoskeletal disease either during or after
residency training.
There is some evidence from a handful of
controlled trials that spinal manipulation does have a
beneficial ef- fect for low back pain, particularly for
certain sub-groups of patients with more chronic or
recurrent problems. On the other hand, in a recently
meta-analysis of 35 ran- domized trails of spinal
manipulation, only 51% of the studies showed an
improved short-term outcome. Most of these studies
had methodological problems, not the least of which
were patient selection bias and difficul- ties of
stanardized diagnosis. Other forms of treatment,
including physical therapy and facet injections, have
also been shown recently to be of little or no benefit,
prob- ably for the same reasons. Treatment is generally
pallia- tive and not curative. Setting specific
therapies aside, there are other issues raised from these
studies. Cherkin et al suggest that the beliefs of family
physicians that no specific diagnosis for back pain
exists other than “back strain” and “slipped disc,” and
that there is little effec- tive treatment other than
expentant analgesia, lead to frus- tration and
therapeutic nihilism. The same investigtators have
recently reported on a targeted continuing medical
education (CME) program designed to improve back
care and patient satisfaction. The primary goal was to
2

seen by the above physicians showed that the interven-
tion had no effect on outcomes of care. Cherkin et al
suggest, after reviewing several options, that negative
feelings about back pain patients induced early in
medi- cal training may override other determinants in
back care outcome.
This may be subconsciously or openly conveyed to
patients creating a negative placebo effect.
Positive placebo effects derive from agreement be-
tween patient and provider on the nature and cause of
the problem, strong assurance on outcome, the use of
instrumentation, and the “laying on of hands.” In their
recent paper, Koeset at comment on the power of the
placebo and the possibility of beneficial effects of
refer- ral to another professional. Placebo modulation
of pain through segmental reflexes as well as cortical
and lim- bic activity through the hypothalamus is well
substanti- ated by the gate-control theory developed
by Melzack and Wall in 1965. Furthermore, Waddell
has shown that, for chronic low back pain physical pain
contributes only
40% whereas psychologic distress and abnormal illness
behavior contribute 31% to the degree of disability, al-
though the contribution by illness behavior may be sig-
nificantly less for patients with acute back pain. Back
pain, therefore, provides a classic example of the
biopsuchosocial model of illness in which social and
psychologic factors play major roles in pain control,
The Journal of Family Practice, Vol. 35, No. 5, 1992
dis- ability, and rehabilitation. Yet the tools commonly
used by family physicians to treat back pain tend to be
those of biomedicine and referral rather than
behavioral and direct manual therapy, and this may
explain why patients are more satisfied with care from
chiropractors, who are much more focused on
musculoskeletal problems and the context in which
they occur.
Referral To Chiropractors
Over the last 50 years, allopathic medicine has had a
deep suspicion and concern about chiropractic. Until
1980, the American Medical Association stated that it
was unethical to refer a patient to a chiropractor, and a
physician doing so was likely to lose membership in
the Association. National chiropractic associations were
only able to achieve full acceptance as a clinical
discipline through winning a historic lawsuit against
the American Medical Association, which was found to
have conspired with other groups to contain and
eliminate chiropractic through ethical prohibitions.
Many physicians, probably a majority, are still re-
luctant to make specific referrals to osteopaths or
chiro- practors. In a survey of a 25% random sample of
chiro- practors in 1973, respondents indicated that 90%
of re- ferred patients attending 10 chiropractic clinics
indicated
552
2
Chiropractors and Back Pain
Table 1. Guidelines for Identifying A
competent
Chiropractor
• Treats mainly musculoskeletal disorders with
manual manipulative techniques
• Does not do routine radiographs on every patient
• Does not extend duration of treatment
unnecessarily (see Table 2)
• Writes a response to a referral and outlines
evaluation and therapy
• Does not charge “front end” lump sum for whole
treatment program
• Graduated from a school accredited by the Council
on Chiropractic Education
• Is willing to have physician visit the office to
observe treatment
• Good feedback from patients on care given
Curtis and Bove
gerous intervention. Over the years, there has been some
jus- tification for these views as a result of unsupported
claims for success in treating a range of medical conditions.
The danger-
ous complications of manipulative techniques, mainly
vascu- lar accidents, occur in very small numbers (about 113
docu- mented cases) and have been used as a weapon
against chiro- practors. The incidence of vascular accidents
following cer-
The Journal of Family Practice, Vol. 35, No. 5, 1992

that 53% had consulted a physician during the current epi-

sode of pain and 19% had been referred to the chiropractor
by the physicians; but a more recent study reported that less
than
1% of patients were referred to chiropractors by other
provid- ers. Some guidelines on identifying a competent
and ethical
chiropractor are shown in Table 1.
There are many complex factors of history, attitude, be-
lief, and professional distrust that contribute to this discrep-
ancy in behavior between the professions. Probably the most
powerful perceptions noted by allopathic physicians involve
suspicion regarding the extend, depth, and validity of
manipu- lative training, particularly the possibility of
“missing? a seri- ous disease. Since the early part of the
century, however, chi- ropractic schools have required a
minimum of 4 years of train- ing that includes medical basic
sciences, general diagnostics, radiology, physical therapy,
and, of course, manipulative therapy, with prerequisite
course work similar to that neces- sary to enter medical
school. In 1979, a commission of in- quiry found the basic
sciences at North American chiropractic schools to be
equivalent to those taught at medical schools. Currently,
atypical curriculum involves a minimum of 4200 hours of
training, of which approximately 200 hours are pa- tient
contact. Doctors of Chiropractic are highly trained prac-
titioners, qualified and licensed to diagnose disease entities
and to refer patients when the treatment necessary is out of
their scope of practice.
Another argument against the use of chiropractic is the
perceived lack of basic scientific evidence and clinical trials
that would justify the use of not only manipulation but other
mechanical and electronic device. Although there is a
consid-
erable amount of neurophysiological research supporting the
theoretical basis of manipulative therapy, basic scientific
evi- dence and clinical trials dealing with this topic are
scarce, as
they are for other modalities used in the treatment of
muscuoskeletal ailments.
Finally, there is the argument that manipulation is a
dan-
2
 cancer may still suffer from mechanical back pain, and ma-
vical manipulation has been reported as between 1:4000,000
nipulation can be effective as long as bone metastases have
to 1:1 million procedures. Almost all complications of ma-
been excluded.
nipulative therapy have involved specific rotary adjustments
of the cervical spine, which comprise about 30% of the 100
million visits per year made to chiropractors. In fact, a num-
ber of these complications have followed manipulations by
allopathic physicians.
Complications of lumbar spine manipulation are even more
rare and usually consist of an exacerbation of radicufopathy
with a herniated disc. However, certain clincians have used
manipulative therapy specifically for lumbar disc herniation.

What is Manipulative Therapyy?

For chiropractors, manipulative therapy is the art of restoring

a full and pain-free range of motion to joints, the theoretical
basis is that hyper-or hypomobile joints produce local and
dis- tant effects as a result of abnormal afferent and efferent
nerve irritation from joints, synovial membrane, and other
soft tis- sues. The ability to perform manipulative therapy is
not easily attained. The communication skills and sensitivity
of the hands to appreciate tissue compliance and subtle joint
movements take some time to develop. Manipulation is
generally performed by taking joints to their end point of
motion (“long lever” tech- nique) and then isolating the joint
to be manipulated by local pressure on prominences of the
articualting bones within the stretched area (“short lever”).
Once isolated, a high velocity but low amplitude thrust is
delivered to the joint, and an au- dible noise usually signified
that the manipulation has been successful. Done properly,
the procedure is painless and the joint has moved past its
passive range of motion, but not out- side of its range of
anatomical integrity. It should be obvious that the
techniques, broadly described here, should not be per-
formed by those who are not adequately trained. It should be
noted that chiropractors also provide physical therapy,
perform radiographic examinations, and advise their patients
about diet and exercise. These adjunct therapies are said to
promote more rapid recorery than manipulation alone but
have not been proven to be of benefit.

Contraindications and Indications for

Referral for Manipulative Therapy

Contraindications for referral for manipulative therapy

in- clude a range of systemic diseases, including arthritis,
bone disease such as infection or metastases, long-term
steroid therapy, evidence of significant cardiovascular
disease, anti- coagulation, vertigo, neurologic disease,
severe cervical spondylosis, and disc lesions with objective
neurologic defi- cits. Less than 1% of all low back pain
patients have an under- lying systemic disease as a cause,
however, and almost all can be screened by radiograph and
sedimentation rate by applying the criteria established by
Devo: presence of neurologic defi- cit; age over 50 years,
presence of fever, weight loss or aden- opathy; steroid use;
evidence of rheumatoid or ankylosing spondylitis, prior
malignancy. These risk factors are rarely absolute; both of
us have treated patients from each of the aforementioned
categories, after accurate diagnosis and spe- cial
considerations have been made. Thus, a patient with breast
2
Chiropractors and Back Pain Curtis and Bove

Chiropractors are highly trained in musculoskeletal diag-

nosis and treatment techniques and are found in many of the
same practice locations as family physicians. Their popular-
ity and presence has increased, and in all states their services
are covered by insurance and worker’s compensation.
Because of the significant economic and professional impact
of this form of treatment, interest in the validation of
manipulative therapy has grown.

2
The Journal of Family Practice, Vol. 35, No. 5, 1992 553

3
 INITIAL PHONE CONTACT

Each medical doctor that received an introductory letter from you should be
contacted by phone within two weeks of receiving your letter. This phone call will be
for the purpose of meeting together personally to discuss ways you can help each
other to best serve the patient. As mentioned in your introductory letter, invite the
doctor to come to your office and spend a few minutes touring the clinic and seeing
how patients are treated. You may want to invite the doctor to lunch and simply try to
include the office tour as part of the lunch hour. Arrange your meeting at a restaurant
that is close to your office so you can easily invite the doctor over while you are on
lunch break. If a lunch meeting is impossible, you may want to try to work out a
coffee break time at his/her convenience and at his/her location to make the meeting
as quick and easy for them as possible. Please be aware that a letter of introduction
will not be enough to generate referrals and new patients. Phone contact and a
personal meeting will go farther in getting results than any other contacts you will
make.

3
 PROGRESS UPDATE LETTERS

Be sure that you have on your Health History form a blank for the patient to fill in
with the name of their general practitioner. Instruct your staff to get this information
with a release and immediately look up the address of that general practitioner so you
can send to him or her progress update letters. If general practitioners learn that many
of their patients are already seeing you as their chiropractor getting good results, it
will lessen their hesitation to refer other patients to you. It also provides a
commonality between you and the medical doctor. The most common ground you
have is the patients and their well being. On the following pages you will find
progress update letters that can be typed into your computer or used manually
followed by an example of what that letter would look like once it has been completed
with the proper information. These initial and final reports should be sent to the doctor
of every patient that comes under your care regardless of whether the patient was a
direct referral.. The only reason for not sending a report is if you feel the MD may be
anti-chiropractic to the extent that he would discourage the patient from receiving
chiropractic care.

Both the initial report (page 19) and the final report (page
20) should be entered into your word processor and
personalized from the forms on pages 21-23.

3
 INITIAL REPORT
[Date]

Bruce Rodan, M.D.

648 US Highway 1
North Palm Beach, FL 33410

Re: [John Doe

Dear Dr. Rodan:

[MU [John Doe presented [him]self to our office for examination and treatment on [6/
18/96] At that time he complained of [major symptom] The patient described the
[pain/condition as [a dull ache with general soreness and occasional numbness in the
right arm]. The patient states that the symptoms are [constant/intermittent] [mild/
moderate/severe in nature and have [not changed/increased/decreased in severity over
time. The problem is exacerbated by [lifting/bending/turning/other]

Examination of the patient using various neurologic, orthopoedic, and

chiropractic tests demonstrated [positive tests] X-rays [cervical spine/thoracic spine/
lumbar revealed [degenerative changes in the lower cervical region]

My initial assessment of the patient’s complaints is [a chronic rotator cuff sprain/strain

with associated tendinitis in the right shoulder and a chronic cervical sprain/strain with
associated myofascitis and segmental dysfunction]

The treatment plans consists of spinal manipulative therapy and [electromuscie

stimulation with moist heat to the [cervical/thoracic/lumbar/other area. [Transfriction
massage has been applied to the supraspinatus muscle on the right/any other
treatment] I anticipate good results with this patient. I will send you
a final outcome report within [i months]

Thank you for [your referral/allowing me to assist in this patient’s health care]

Sincerely,

Bundle 0. Bones, D.C.

3
 FINAL REPORT
[Date]

Bruce Rodan, M.D.

648 US Highway 1
North Palm Beach, FL 33410

Re: [John Doe

Dear Dr. Rodan:

[ML] [John Do presented [him]self to our office for examination and treatment on
[6/18/96] At that time he complained of [majors-vmptom] The patient described the
[pain/condition as [a dull ache with general soreness and occasional numbness in the
right arm]. The patient states that the symptoms are [constant/intermittent] [mild/
moderate/severe in nature, and have [not changed/increased/decreased in severity over
time. The problem is exacerbated by [lifting/bending/turning/other]

Examination of the patient using various neurologic, orthopedic, and chiropractic

tests demonstrated [positive tests] X-rays were performed at this office. The [cervical
spine/thoracic spine/lumbar spine/other revealed [degenerative changes in the lower
cervical region]

My final diagnosis is [chronic rotator cuff sprain/strain with associated tendinitis in

the right shoulder and a chronic cervical sprain/strain with associated myofascitis and
segmental dysfunction]

Treatment consisted of spinal manipulative therapy and [electromuscie stimulation

with moist heat to the [cervical/thoracic/lumbar/other} area. [Transfriction massage
has been applied to the supraspinatus muscle on the right/any other treatment]
The patient has progressed [very/moderately well under conservative care. [One
hundred percent symptomatic relief has been attained. [List any limitations or
continuing problems if total symptomatic relief was not attained]

Thank you for [your referral/allowing me to assist in this patient’s health care]

Sincerely,
3
Bundle 0. Bones, D.C.

3
 CREATING AN INTERDISCIPLINARY REFERRAL
NETWORK INITIAL REPORT TO MD
Medical Doctor’s Name and Address:
d)Lying
e)Sitting
f) Standing
g) Walking
2. Patient’s Martial Status: single / married h) Moving from a seated to a
(circle one) standing position

3
3. Patient’s i) Other
Name: first last j) Other
4. Male Female (circle one) k)Other:

5. Date of First Office Visit: 13. Positive Tests Included:

Low Back:
6. The major symptom is: a) Lasegues
b) Braggards
c) F. Patrick
d) Trendelenburg
7. This patient has a .....Pain Condition f) Leg Lower
(circle one) g) Patellar reflex
Type of pain condition: h) Achilles reflex
a) Sharp stabbing pain i) Decreased lumbar range of
b) Deep pain motion
c) Aching Cervical:
d) Dull ached) Dull ache a) Forem. comp.
e) Soreness b) Shoulder
dep. f) Numbness c) Soto Hall
g) Numbness and tingling d) Adson’s
...of the ---------------------- f) Triceps reflex
9. Constant Intermittent (circle one) g) Radial reflex
10. Mild - Moderate - Severe (circle one) h) Decreased cervical range of
11. Patient’s Condition has: motion
a) Not changed Other:
b) Increased Other:
c) Decreased in severity over time Other:
12. The Problem is Exacerbated by: 14. X-rays Were Taken of the:
a) Lifting a) Cervical spine
b) Bending b) Thoracic spine
c) Turning c) Lumbar spine

3
INITIAL REPORT TO MD

3
d) Other: l) Other
e) Other: m) Other
f) Other 18. Treatment Area:
a) Cervical
b) Thoracic
c) Lumbar
15. X-rays Revealed: d) Other:
a) Degenerative changes in cervical spine e) Other:
b) Degenerative changes in lower cervical f) Other:
spine 19. [Optional] Add a complete
sentence about
c) Degenerative changes in thoracic spine any other type of treatment.
d) Degenerative changes in lumbar spine
e) Other:
f) Other:
g) Other:
h) Other:
16.Initial Assessment of the Patient’s 20. When will you send a final report?
Condition (Circle one)
1 2 3 4 5 6 7 8 9 10 11 12.
Diagnosis: days weeks months
21. Thank The Doctor For: ---------
a) Referring the patient.
b) Allowing me to assist in this
patient’s health care.
17. In Addition to Spinal Manipulation Patient
Treatment Consisted of:
a) Electromuscle stimulation
b) Moist heat
c) Ultrasound
d) Diathermy
e) Manual traction
f) lntersegmental traction
g) Hot packs
h) Cryotherapy
i) Other:
j) Other:
k)Other:

3
 FINAL REPORT TO MD

1) Patient’s Name

2) My Final Diagnosis Is:

a) Same as the initial diagnosis

b) Other:

3) The Patient Has Progressed:

a) Very well

b) Moderately well

4
4) The Patient Has Received % of Symptomatic Relief

List Any Limitations or Continuing Problems if Total Symptomatic

Relief Was Not Achieved:

4
[Date)

Bruce Rodan, M.D.

648 US Highway 1
North Palm Beach, FL33410

Dear Dr. Rodan:

I am sorry that we were unable to work out a time to meet together in the near
future. We both have very busy schedules and many times meetings are difficult to
arrange.

In respect of your time, I am sending you a gift, a book that I believe you will
find to be very informative and helpful. It covers a lot of the information I had hoped
we would be able to share in our meeting. Please read the book at your convenience
and hopefully at sometime in the future we will be able to arrange a time to meet
together and discuss how we can work out a professional working relationship for the
benefit of your patients.

I hope you enjoy the book.

Sincerely,

Bundle 0. Bones, D.C.

Enc.

4
[Date]

Bruce Rodan, M.D.

648 US Highway 1
North Palm Beach, FL 33410

Dear Dr. Rodan:

I just want you to know how much I appreciate the opportunity of meeting with
you and I look forward to more of the same.

As a way of saying thank you for your time, I am sending you this special
educational study by the U.S. Department of Health and Human Services that I
believe you will find to be very informative and helpful. Thank you again for your
time and I certainly look forward to a friendly working relationship with you for the
benefit of your patients.

Sincerely,

Bundle 0. Bones, D.C.

Enc.

4
 PUBLIC RELATIONS ACTIVITIES
1. Sporting Events

Many in the medical profession have hobbies that include golf or a health club.
This can give you another opportunity for common-ground communication that would
establish a good working relationship and can include sponsoring a golf tournament or
a racquetball tournament. This should become an annual event and should be
promoted as such. If you are concerned about the attendance, you may want to
co-sponsor the event with your local medical supplier or another medically oriented
company. This can add validity to your program and help to ensure a certain number
in attendance. However, be absolutely certain that you are recognized as the major
sponsor and be visible during the events.

How to Sponsor a Golf

Tournament

Time for the Tournament The most popular day for this tournament appears to be
Thursday. However, we would recommend that you talk to some of your friends that
are MDs or attorneys and find out from them what their preferred day/time would be.
We want to fit the schedule of those professionals who are most likely to come.

How to Invite Send a brief letter of invitation that could also include a promo flier.
Send this out 40 days in advance of the tournament date. This would be followed up
the next week by a personal phone call. Your phone contact will be the most effective
means of getting them to the tournament. The letter gives you a source of reference.
Encourage them to put together their own foursome. If they are unable to put a
foursome together, then you will put them with other individual professionals that they
would not necessarily know. Many times they will already have MDs who are golfmg
friends, and this will help you to get more MDs with them, promoting and building
your tournament. They will be glad to put together a foursome since they probably
already have one (and may be golfing on this day anyway). This time you are picking
up the tab. It’s a win-win deal.

Expected Response As long as you have a foursome, it will be worth doing. But a
successful golf tournament would probably be three to five foursomes.

Location This tournament will represent your professional image and success;
4
therefore, if you are a member of a prestigious, private club, that would be great. If
not, you may have a friend who would help you arrange the tournament at his/her
club. If that is not possible, then make arrangements at the public course that has the
most prestigious reputation.

Chiropractic Presentation: Arrange for the MD’s to meet at your office either 40
minutes prior to the time that you would need to leave for the golf tournament or have
them meet after the tournament at your office for 40 minutes for a tour of your office
and short chiropractic-education presentation. Of course, if you are not comfortable
making a presentation to them, this is not a necessity. However, it is a perfect
opportunity for chiropractic education. You can use facts and information from the
brochures that we have recommended or some of the materials you presently use for
your spinal care class. Another possibility would be a slide presentation by Dr. Arthur
Roft of Spine Research of San Diego,(619) 423-9860.

II. Holiday Gifts

In December you need to plan on spending from $20 to $40 on each office to
present them with a special holiday gift. The range of money spent is determined by
the response from the MD and your budget. In other words, be generous with those
MDs who have already sent referrals and those who have been open, responsive, and
cooperative.

1) Have the gift presented to the office early in the month so it can serve for
Hanukkah or Christmas will get the most notice before it would possibly get
lost among many other presents later in the month.

2) Consider having the gift delivered by a public relations person who would
represent your office in a very professional way. This will make sure that the
proper people receive your gift and it also allows you to know what their
response is to your holiday presentation. The other alternatives, would be
delivery by mail of by the business where your purchase was made. The most
effective method, however, is delivery by someone from your office.

3) Be creative. By this time you should have had the opportunity to get to know
many of the professionals on your list and you may know their personal likes
and dislikes. One doctor may be a golf nut and you could give him or her a gift
certificate.

4
for a green-fee at their favorite course. Another sports fan might appreciate two tickets
to the professional football, baseball or basketball game. They may be music lovers
and would enjoy tickets to a musical or evening concert. You may know their favorite
restaurant and could give them a gift certificate at that restaurant. One doctor might
really enjoy having a picture of Bill Clinton and another one a subscription to the
Rush Limbaugh newsletter. For most of the MDs on your list, you will probably be
presenting them with a generic type of holiday gift. Here is a list of possibilities: a
holiday flower arrangement for the office; a best-selling business book; motivational
cassettes; food of any kind (fruit baskets, chocolates, decorative cans of popcorn,
catered displays from restaurants such as shrimp cocktail, etc).

Be sure your holiday gift is something that would be enjoyed by anyone, except
in the case of those doctors you know who have particular likes. You probably would
not want to choose a gift such as liquor or a Rush Limbaugh newsletter as a generic
holiday gift.

III. TV and Radio Talk Shows

If you have a public health program on TV or radio, many of these MDs could
be contacted to appear as guests on your program. Even if you do not have a radio or
TV program at this time, it may be a good idea to do a 3-week series to promote your
clinic and have MDs as guests. You can interview the medical doctor and once again
build a relationship of how chiropractic and medicine can work together. It also gives
you another reason to send them a letter and contact them by phone. It will give you a
reason to meet with them for lunch and a good idea would be to see if they could meet
you at your office. It seems to make a real difference when you have the medical
doctor see your office and even observe your work. That truly does build good
credibility. Once again, the reason members of the medical profession do not refer to
chiropractic is due to not knowing chiropractic.

IV. Phone Contacts

You should schedule your public relations activities in a manner to have a

reason to call the medical doctors in your area on a quarterly basis. One phone call
would be a follow-up on your letter of introduction, another to schedule doctors as
guests on your radio or TV talk show. Another could be a follow up to see if it is
possible for them to attend your managed care seminar. Other phone calls can be to
their registration (or lack of registration) for your sporting event. There could be a

4
phone call inviting them to an open house or a meeting to come to your office. There
could always be phone calls with the common ground being the patients.

V. Sponsor A Seminar

Once a year sponsor a seminar at your office for these health care providers.
Again, if you are concerned about attendance, you may want to co-sponsor the event
with your local medical supplier, software distributor, or other medical vendors.

1) Have the seminar on a weekday evening and let them know that it will only
last for a specific time period. Check with some of the MDs with whom you have the
best relationship to see what day and time they would prefer. Offer other possibilities
such as a noon luncheon seminar from 12 to 2 p.m.

2) Provide a very elaborate display of refreshments or even consider a catered

meal. You could possibly have the-seminar at a favorite restaurant in a reserved
meeting room if this would be a draw to get them there.

3) Part of the seminar should be used to introduce all those in attendance at the
seminar.

4) Another portion of time should be used to introduce yourself to anyone who

might be new. Inform them about your clinic, your practice and chiropractic. Thank
them for their referrals. Let them know how much you enjoy working with them, and
thank them for coming to the seminar. Advise that you are planning on making this an
annualevent and would be open to any ideas they would have for future dates.

5) Consider using an outside speaker. We don’t want to make this seminar a huge
expenditure of money, but want to make it nice enough to draw the people we want in
attendance and make it successful enough that they will want to come back. There
might be some good chiropractic speakers from outside your city,an expert on
managed care, your state senator or someone who could bring to your seminar the
latest developments in health care. Another possibility would be to create a small
panel

4
made up of you and perhaps an attorney or two and MD’s that you either get referrals
from or would like to get referrals. Most of these speakers would assure you of having
people in attendance and at the same time would not be very costly. Another
possibility may be a well-known seminar that is coming to your city that you know
would be good for them to attend. You could invite them and pay their registration.
An example would be a Dan Murphy seminar in your area (Daniel Murphy, 148 A
Ray, Pleasanton, CA 94566, (510) 837-1789). Don’t be afraid to get some feedback
from those that you have the best relationship with to see what they think they would
enjoy the most.

VI. Year-End Holiday Party

As an annual event, sponsor a social gathering to be held sometime between

Thanksgiving and New Year’s Day. This social gathering should have an end-of-
year/ holiday season theme that is inclusive to people of all faiths. Make this party a
first-class, festive celebration. If you have a nice home, the party can be catered to
your home. If you do not wish to use your home, a country club or other prestigious
setting should be used. You may want to include hors d’oeuvres, beverages,
professional musicians, special floral arrangements, holiday decorations, catered food,
valet parking, etc. You may consider inviting all prominent political figures and other
prominent business leaders that you know personally, as they will draw the other
guests.

Some doctors prefer not to do a holiday-season social event. In that case, we

suggest holding an annual political party event. The advantage of holding a political
party social event is that during election year, the political candidates are more than
happy to attend social functions and the medical and legal professions are often
interested in attending events where political candidates will be present. This social
event should be handled in the same way described in the preceding paragraph. Again,
both of these social events, as well as the sporting events you sponsor, should always
be promoted as annual events so they will build reputation over time and people will
anticipate being invited on a regular basis.

4
 ANNUAL CALENDAR AND TRACKING FORM

Orchestrating this entire plan is more detailed than it may appear. In fact, one of
the major reasons for discontinuance of an interdisciplinary referral network is
confusion in what has been done and what has not been done. You should use two
forms, the Annual Calendar and the Tracking Form to monitor your progress.
The Annual Calendar, found on the following page, allows you to establish a starting
date and completion date for the major events that will take place if you follow this
program in it’s entirety. It should be filled out one year in advance and you should be
careful to add the major deadlines for any events you elect to add to this project as
time passes.

The second form, entitled Tracking Form, allows you to track and monitor the
events of individual doctors. This tracking form should be photocopied so each
medical doctor you have contacted has a tracking form in a separate notebook. Be sure
to use the Comments section of this tracking form to make comments on the
receptivity of the doctors. This information is useful in the event someone is helping
you work on the project and in deciding which doctors you should continue to contact.

The bottom of the tracking form should be used to track those patients that have
started care in your office recently who use one of the doctors you are contacting as
their primary medical doctor. Many times we know that we have several patients from
a specific medical doctor but cannot remember which patients see each particular
doctor. By tracking this information, you will be able to have those patients’ names at
your fingertips for reference when speaking with the medical doctor.

Eventually you should set up a database in your computer so patients can be

sorted by their primary medical doctor or referring physician. But, if you are not now
capable of doing that, we suggest you use the bottom of the tracking form until you
have a computerized database established for this purpose.

4
CREATING AN INTERDISCIPLINARY REFERRAL NETWORK

5
ANNUAL CALENDAR
Starting Completion

• Copy Tracking Form and assemble tracking notebook

• Acquire/develop list of doctors to contact
• Contact mailing house or enter names into computer
for mailing purposes
• Order brochures from The Journal of Family Practice
Pran Manga & Associates and/or The Foundation
of Education and Research
• Print individual letters of introduction to each
doctor onthe mailing list
• Make initial phone contact with each doctor
• Implement the use of initial reports and final reports on
all patients
• Order newsletters to the medical profession from
Chiroventures Ltd: (800)
982-2882
Public Relations Activities

• Decide on a sporting activity to sponsor

• Confirm location and date for the sporting activity
• Contact medical supply house about
co-sponsoring the event
• Print invitations
• Mail invitations
• Follow-up phone contact
• Purchase gifts, prizes, trophies, etc.
• Purchase holiday gifts
• Send/deliver holiday gifts
• Start weekly radio or TV show
• Arrange for medical guests
• Arrange date and place for a health care seminar
• Arrange for speaker
• Find a co-sponsor
• Promote the seminar
• Provide for refreshments, meals, and hand-out materials
• Confirm outside speaker if necessary
• Plan year-end holiday party date and place
• Plan all holiday party activities
5
TRACKING FORM

5
Doctor’s name: Phone number:
Address:
Office Manager’s name: Specialty:
Doctor’s personal
interests/hobbies/pastimes
Spouse’s name:

Completion
Date:
Letter of Introduction sent with brochure No .
Comments:

Initial phone contact

Comments:

Progress letters including initial & final reports indicating with

doctor’s patient
Comments:

Doctor’s name entered on list of doctors receiving medical newsletter

Comments:

Educational tapes sent I delivered

Comments

Invitation to sporting event

Comments

Telephone confirmation of sporting event attendance

Comments

Holiday gift sent / delivered

Type of Gift
Comments

5
Invited to year-end holiday party
Comments: [Attended? Yes / No]

Letter contact for radio talk show

Comments:

Personally invited as talk show guest

Comments:

Invitation to seminar sent

Comments:

Phone call re: seminar attendance

Comments

List of patients in common: Name: Direct referral? Yes No

5
 CONCLUSION

The letters, newsletters, public relations activities and phone calls that you will
make in working through this packet should provide you with constant contact with
the medical profession that will make a positive impact on building medical referrals.
You do not have to do every single activity in this booklet in order to be successful.
But, you will certainly want to do a vast majority of them. While this plan cannot
guarantee success, there is certainly one thing for sure: You cannot do any worse than
if you do nothing! It is almost certain that if you were to carry out these activities for
a
period of two years, you would see good results. This is the best program available for
building a referral practice based on a professional relationship with other disciplines.

As part of our total Body Care Integrative Medicine

approach, our exams include, in addition to the Standard H
and P exam, a Postural Balance and Endothelial Scan. This
assures us the we have applied an Evidence Based
approach for any Endothelial Cell Dysfunction as well as
Brain Function and Vestibular Balance.

Our practice is strictly referral based, and we offer in Office

screenings of patients presenting with either Lifestyle
Habits (LAQ – Trale) – Call Dan – WELCOA – Wellness
Inventory – James Stroehecker -

358 Clinics
WELCOA clinics

Anywhere blood travels in your body, the lining of the walls

is full of Cells Called Endothelia. And dysfunction in these
cells, and their function or dysfunction is an early warning
sign, or a Biomarker – of your health. Two examples of
Endothelia (or blood quality is the Heart, as well as say the
Penis in Men. Below is a list of a few studies that have
detected Heart Disease, as well as Erective Dysfunction
5
occurring at the same time. So an E C Test is actually an
essential tool in the emerging Preventive Care based model
of health. An Endothelial Test is to your body, what your
tune up test is to your cells care. You can pay now, for a
$250 Test now, or pay later for a $25,000 and up surgery.

Have you been Endoed lately.

Take Care Of Your heart.,