In the second episode of this two-part series, chiropractor Dr. Albert Scales explains how he contacts and builds rapport with a prescribing health care professional to collaboratively help a patient with an opioid dependency. Tune in to hear how he coordinates care to help their shared patient safely taper their use of opioids to treat their neuromusculoskeletal (spine, muscle, joint, and related nervous system) pain, while staying within the chiropractor’s scope of practice. Dr. Scales also discusses when and how to use OCA’s Opioid and Pain Reduction Collaborative’s tools, including the Manual Therapy as an Evidence-Based Referral for Musculoskeletal Pain Clinical Tool developed with the Centre for Effective Practice (CEP). (22 minutes)
Key links discussed:
About Dr. Albert Scales:
Since 1981, chiropractor Dr. Albert Scales has treated many patients recovering from automobile accidents and workplace injuries, including many with opioid dependencies. He also served as a chiropractic consultant for WSIB Ontario’s Hamilton office for 10 years and has worked for 20 years as an Independent Medical Evaluator for automobile accident claims.
Dr. Scales is familiar with OCA’s Opioid and Pain Reduction Collaborative, having participated in a focus group to inform its development.
His multi-disciplinary practice is located at Lakeshore Chiropractic Group in St. Catharines, Ontario. He is also a chiropractic provider at Quest Community Health Centre.
Dr. Scales is the current president of the Niagara Chiropractic Society, a Rotarian, and received OCA’s Political Service Award in 2004 and its Community Services Award in 2001. He graduated from the Canadian Memorial Chiropractic College (CMCC).
We are taking a break in August for you to enjoy your summer but will be back on September 15, with an episode on How Extended Health Care Trends Affect Your Practice.
Episode 2:Building Rapport with a Prescribing Health Care Professional
Welcome to ON Spinal Chat, where we explore what O-C-A is doing or supporting to help enhance your patient care, grow your practice, or advance the chiropractic profession.
I'm Leslie, and this is the second episode of our series on how you can help address the opioid crisis. In part one, chiropractor, Dr. Albert Scales outlined how to ask a patient about their opioid use for M-S-K (musculoskeletal) pain and if they are comfortable with you approaching your prescribing health care professional.
In today's episode, Dr. Scales returns to explain how he initiates contact with the patient's medical doctor or nurse practitioner to co-ordinate their care. And we'll chat about how he then collaboratively works with the prescribing health care professional to help their patient safely taper for their use of opioids, all while staying within scope.
Dr. Scales will also explain how he uses various OCA tools, including the Manual Therapy as an Evidence-Based Referral for M-S-K (musculoskeletal) Pain clinical tool that we developed with the Centre for Effective Practice, and he'll highlight why M-Ds and N-Ps will value this tool.
Thank you for joining me, Dr. Scales. In our last episode, we talked about engaging a patient to discuss their opioid dependency within the professional scope of practice and attaining their permission to speak with their primary care physician or their prescribing health care professional. But how do you initiate dialogue about pain management with the patient's prescribing health care professional when you don't know each other?
Dr. Albert Scales:
It's like going out on a blind date. You ever done any of those? Think about it. If you're going to make a call or even send a report of findings or whatever the case is, even an opioid dialogue to this person that you have absolutely no clue of how they're going to respond – that's got to be the most difficult, the most scary conversation that you'll ever think of having. But the one thing you have in your corner that the family doctor, let's say, does not, unless they referred you to that patient, is the patient themselves. I think that's part of your conversation.
“Hey, by the way, John, does your doctor know you're coming here for this type of care?” You'll have a lot of patients go, "No, not really. I'm just sick and tired of having to take all these medications. I've just heard about you, and I wanted to come in." That's going to be a cold call because you have no understanding of what may go on in that conversation. However, you may want to then ask them, just as you're doing the treatment, “How do you like your doctor?” If they say, "He's a pretty good guy and he's pretty open about sending mail for these tests or what have you …" It's almost like you’re out with a buddy and you're finding out a little bit about somebody that you may want to date, and you say, "What do you think that person is like?” “He's really cool."
That's when you're going to start putting up barriers too. And that doesn't mean that you don't send out a little report to the doctor, somebody that you've never ever had a conversation with, and you have clue how they're going to respond. I always send out periodic updates or even just an initial report. It's out of courtesy because the fact that this is a collaborative effort, you're still adding more information and more clinical details to your initial report. Now, that guy could turn around and look at that or just shred it immediately. But I don't think that happens. You have to understand everybody is on the playing field and that the playing field is the patient.
Usually, I will take my letterhead, I put the name of the patient in a big box underneath the letterhead with the birthdate underneath, and on the one side I'll put down the date just below that. I'll simply say, "Dear Dr. So-and-so, this patient was first seen in my office on this date." And then you want to outline it almost like a prescription pad, just a piece of paper they're used to seeing anyways. So put down things like H-X. Mary came in with this back pain she's had for a long time. She mentions that there are no specific objective symptoms, but she's very much concerned about her opioid use.
You may want to talk a little bit about that. If you're a little uncomfortable, then don't go there with opioids. So you don't want to be putting in your report, "By the way, Mary is a little sick and tired because you're trying to give her all these medications." That's going to get your letter shredded awfully fast. What you want to do is typically state why Mary's in and then what you may want to say what your diagnosis is and then go through your treatment plan. And in that verbiage you may also want to say that, "She's earnestly, hoping that she can reduce a lot of her dependency on the pain meds." And that's it. You don't give them a lot of details because they do not want to look at a lot of verbiage from some chiropractors.
Now, everybody likes stroking, everybody likes to be felt important, so a little line that I put on these notes to the doctors, and you don't keep putting this because then you're not checking all your notes, but just usually on the first initial report I'll say something nice on there saying, "Thank you for allowing me the opportunity to assist in the management of your patient." That's it. That's very simple because guess what? I'm not trying to say to this person, "Well, I got him now and I'm going to get him fixed and I'm going to show you." You're not saying that, but when you say that little line at the end it encourages a team approach. This is what we're trying to say right now with this social initiative, with Opioid and Pain Reduction Collaborative, we are collaborating with people.
You have no idea how many of my colleagues in my 40 years of practice said, "I don't want to talk to the doctors because they don't care about us." You've got to be kidding. Under today's rulings and concerns and scrutiny, they would love if the patient is out of their office to come back to see you.
If, for example, the patient comes into you and says, "I'm here because my friend said this would be a great place to come to." And then when you do talk about the doctor because you want to find out “How do you like your doctor?” “Yeah, he's pretty good. In fact, I did tell him I was coming to see a chiropractor and they said, ‘Oh, that's great.’" Ah, now you're on first base because you've already had some verbiage from the patient that says clearly that that family doctor is happy that they're now perhaps trying something different. They're looking at an alternative. That's a person that you have to send a letter to immediately.
I just had a lady today and this was the lady I was telling you about that had a motor vehicle accident that had come to see me and gone through all these other providers. And I said, "Let's definitely try something different because going down the same road is not going to help you." And she said, "I understand."
She finally came in today and this just made me feel so good. She said, "You know, I can't believe how much better I'm feeling." And I said, "Really?" And she said, "Yes, I think I did tell you that my doctor told me that it would be okay to see a chiropractor or a massage therapist." And I said, "Fabulous." And I said, "Wait a minute, you said you were on some opioids before?" "Yeah, Percocet." And she said, "I've been on six Percocets a day, I'm now down to two to three every week."
Dr. Albert Scales:
Yeah. And I said …
And what period of time has that been over?
Dr. Albert Scales:
Well, she had the accident last spring. I didn't see her for several months during the lockdown of COVID. She never thought she was feeling better, but she was actually increasing her meds throughout that time because COVID was a stressful time.
And also, here's another thing that'll affect a lot of patients increasing their opioid use, maybe not necessarily pain, what's happening in life. You think this COVID issue is not stressing them out? That's going to activate more pain meds.
Her husband passed on. She had to put her dog down and this is just a horrible time for her.
So we got her back in the office, probably on a period of about three to four months, she was feeling so much better and she can't believe this. Now there is a person that literally I would hit a home run with. There's a person that I will now send a letter to because now I'm not only setting the initial letter. Now I'm sending an update report. This was what she told me today, and by the way, just to let you know as a general interest here is the protocols that I'm using, and this is what you send them.
And now you send them this Opioid and Pain Reduction Collaborative because now you have somebody saying that “this has really helped me, I've reduced my pain meds. I can't believe I feel this good.” So, you don't send them a lot of this information but that's when you let them know that “you know what? I thank you that we're working together on this.” It's got to be a team approach.
I'm wondering, do you find there's any difference when you initiate contact with a nurse practitioner versus a physician to co-ordinate care of a patient who has an opioid dependency?
Dr. Albert Scales:
Yeah, in the larger urban centres, the family doctors may be very busy, or they may be just doing virtual calls right now. It will be probably easier to contact the nurse practitioner. Nurse practitioners are there, and they serve a vital role.
Particularly if you're dealing with a vulnerable patient that is coming into your office that has reached the end of their line and they're seeing you because there's no other options. “I can't even see my family doctor anymore, but they keep passing me off the nurse practitioner.” That's the dialogue you may hear from the patient. If they have a better rapport with the nurse practitioner, then certainly gravitate to them.
The nurse practitioner may be a segue to the family doctor too.
You've obviously been doing this very well on your own, but within the Opioid and Pain Reduction Collaborative, we've developed a chiropractor's tool kit and it includes pain reduction forms for low back, neck, and shoulder pain, with fillable areas.
Now, we've developed these tools to help chiropractors provide an informed referral and to start the dialogue with prescribing health care professionals. What are your thoughts on these tools? Do you think they may save others some of the steps that you've gone through?
Dr. Albert Scales:
Oh yeah, I totally agree. And that's the wonder of utilizing information that's already so incredibly concise and put together for us.
Let's face it, if I send out an initial report and I don't know what the response of this primary health care practitioner is going to be like. And it could even be, let's say a nurse practitioner. I may not send along this pain reduction tool right away because you've just started to see the patient. But in the verbiage, I may put down that as part of my treatment that I will be following clinical practices set out by the Centre for Effective Practice. That almost kind of wets their whistle a little. So, you're not giving them all this information.
It's much like going out buying a car. You basically may not pick up the brochure immediately but when you start really thinking, "Hey, that's a nice-looking car," you automatically want to get a little bit more information. It's my comment to a lot of the new practitioners out there and even somebody that may be a little nervous sending an initial report out to a doctor. If you have a patient that says, "You know what? My doctor said, 'You have to go see a chiropractor or a massage therapist because I am running out of options.'"
And this is what this doctor said by the way to the patient I was just telling you about. If you get that type of comment from your patient that a family doctor has told that patient to see a massage therapist or see a chiropractor because I have run out of options and believe me, they are running out of options because they're being scrutinized like never before and they cannot keep increasing the med dosage to these patients in frequency. If you have somebody saying that, even if it's on the first visit, then 100% send out this pain reduction tool. I have them right here in front of me, neck pain, low back pain, shoulder pain.
These pain reduction tools have been very clearly outlined. Any one of us that have treated patients under W-S-I-B or under an M-V-A program, know that we should be utilizing language that is standardized between the W-S-I-B, between the motor vehicle accident, but also standardized so that it is accepted and understood throughout other treating health care providers that we may be collaborating with. It's so important that we all talk in the same language.
We can certainly talk philosophically to our patients on a one-to-one basis, but in this world of connection, it's so important that whether it's W-S-I-B, whether it's M-V-A, whether it's chronic care, whatever reports that we're sending out to allied health care professionals that we want to associate with, that we want to have a collaboration with, that we say the same language.
And let's face it, the majority of these doctors, if not all of them, they scan these things and it's not to going to the patient's file. But the more they see these coming across their desk, they're going to realize that we're a force to be reckoned with, that we're there to help them. We're not there to steal their patient. We're not there to show them how it's done. We're there to be part of a team and that's how you get the cooperation out of these individuals.
I think these pain reduction tools are fabulous but the way in which you initiate it, that will come with practice. But believe me, this is a wonderful step-by-step approach that looks professional and it will get you results, period.
As you know, one of the key components of the collaborative is the Manual Therapy as an Evidence-Based Referral for M-S-K Pain clinical tool that was developed with C-E-P. Now, have you shared that with any of the physicians or nurse practitioners that you've worked with?
Dr. Albert Scales:
Yeah, I have. If you send that out to somebody that has no clue what goes on behind your doors, the worst-case scenario, they'll just throw it away. But I think if any of these individuals have been up on current research strategies that are being done right now, they are looking for other ways, you're becoming an option for them. I think what's very impressive about this forum is, it's not coming from you. Let's say a person is really at their wit's end, I think that's an important phone call to make too and not just a letter. Let's say you do phone these individuals, I think knowing that this is a collaborative effort, that it is from the Centre for Effective Practice, it speaks volumes.
I think a lot of them don't realize how important manual therapy is. They understand it from physiotherapy viewpoint, they don't really understand 100% what goes on in the chiropractic office. Again, they think it's a 30-second treatment where they're in and out and they're being manipulated, and they're being seen three or four times a week for the rest of their lives. This periodic communication that you have with them educates them more.
If you do contact a physician, the number one thing I say to people to do is “Don't make this all about you, the common denominator here is the patient.”
You want to be respective [sic] of the practitioner's time. And nine times out of ten, I know when I've contacted them, they're very happy that I've given them a call. And then when that happens, yeah, that's when you... “by the way, I have some information here that relates to the efficacy of manual therapy, particularly as it applies to opioid and pain reduction. Would it be okay if I send you a copy of this?” And they said, "Yeah, absolutely." There's so many ways in which you can utilize this.
What's the reaction been? Can you recall a specific scenario?
Dr. Albert Scales:
Well, yeah, the reaction is that (chuckle) they'll refer a patient back to you because right away they're thinking, "Hey, this ain't too bad after all."
You know what it is? I think it's, you're keeping them abreast of what you're doing. I said this over the years, a lot of them have no clue what goes on behind your door. So, when you send them information like this they go, "Hey, this is pretty cool," because this is stuff that they're aware of. This is maybe information they need, they need something to put in their files. It gives them a little bit of a steppingstone to even their own provincial association and watchdog, shall we say that “I doing my part now because I'm not the be-all and end-all, I'm trying to work in collaboration now with other health care providers, namely this chiropractor, and here's some of the information that they've been sending us.” So that looks good on their part too.
Yeah. I think you've alluded to a little bit of an urgency underneath all this and that there's more pressure than ever before on primary care providers to look a little further. Am I hearing that correctly?
Dr. Albert Scales:
Oh, you're hearing that loud and clear. The norm before was people were taking anything they get a hold of from their doctor. This is a different world we're living in right now. Everybody has to be held accountable. We as chiropractors have to be held accountable. Physicians have to be held accountable. There's not a month that goes by that I don't hear from a patient the name of maybe a physician in the area that has maybe lost their prescription privileges. And that's got to be incredibly difficult for them. It's not saying those people are bad individuals. They're not. Sometimes they just are at wit's end. This is a perfect opportunity for you to give them another option.
And that's exactly what this one family doctor said to the patient that came today, "I have run out of options for you. Why don't you go check out chiropractic and massage?" So that's one of the reasons why you have to be comfortable talking to your patient about what discussions have they had with their family doctor overseeing someone else. You will get a lot of information from that. It'll help you to know whether or not this person is going to be open to your conversations. But even if the doctor is not, every single one of these doctors are under close scrutiny right now.
Certainly, COVID-19 has become the major issue of concern. But when this horrible pandemic is over with, people are still going to be having pain, but they're going to be back to square one. We are living in a different world. They are looking for options and this is an incredible time for us to collaborate.
I don't want to be an island to myself. True health care has to be reaching out, has to be sharing, has to be helping because a patient is going to see that. If you think you have all the answers, you're going down the wrong path. There's more answers out there that we'll maybe never understand. It's so scary to me how many chiropractors have felt nervous, or they just feel that they don't want to have a relationship with an M-D.
And I've got M-Ds that will refer to me perhaps once a month. I may have an M-D that may refer to me once a year. The point is, you've still made the connection. If they see your name coming across their desks regularly, and believe me, I've heard it. Patients will say, "Well, I'm seeing this chiropractor." "Well, I don't necessarily like chiropractors." "Well, I'm seeing so-and-so." "Oh yeah. I heard about them." "Okay, good." Because your name is going to be out there, more now than ever they are looking for options.
A lot of the younger physicians that are coming out, they're looking for collaboration. We have chiropractors now working in research, in hospitals, and in universities. This is an incredible time to work together as a team. That’s what patients deserve, particularly in light of this opioid pain crisis.
Would you say then when you reach out to the prescribing primary care provider it’s about that patient initially but it’s not generally the beginning and the end of your rapport?
Dr. Albert Scales:
One hundred per cent because you start to see this. I'm sure people have seen referrals to even a fellow specialist, but they don't even call them dear so-and-so, they'll say, "Dear Tim." They start using first name basis because it's like you're getting together for a beer. The reality is that I'm not the best, you're not the best, but together we're incredible because the main focus is that patient. We've heard this and everybody again thinks, "Oh yeah, patient-centered care." My God, that couldn't be more valuable than it is today.
But this pandemic has lost a lot of these poor souls because “You know the last time I spoke to my doctor,” they say “was like six months ago. I'm on a virtual call. I'm getting my prescriptions renewed or my God, I can't get my prescriptions renewed now because, well, he wants to see me but he's not back in the office for maybe another month, but he'll let me know or she'll let me know.” How does disastrous that is. We truly do have a leg up to become collaborative. Truly there is no better time to utilize this information. We got a lot of work ahead of us but that work will be valuable.
What's the biggest change we can hope for to address Ontario's opioid crisis?
Dr. Albert Scales:
I think the biggest change is to see a reduction in opioid dependency. If patients can’t have easy access to their doctor, and if their doctor is now being restricted on opioid prescriptions, whether it'd be dosages or frequency, it's going to lead them down a really slippery path into illicit drugs and it has happened. If somebody is recreationally doing something just to get high, that's another group entirely because there's other socioeconomic, financial, and mental issues that you're dealing with.
But when we're dealing with a person that is dealing with pain, going forward we're definitely going to be continuing to hear about opioid use.
I think we as chiropractors shouldn't be pointing fingers, “this should have never have happened.” That's past tense. We’re all – pharmaceutical companies, physicians, everybody is all learning from mistakes now. We're living in a heightened state of awareness.
The biggest change that we can hope for to address this is working in collaboration, which we are just starting to do now with people that are able to prescribe these medications. And to show them that we don't have all the answers but we're here to collaborate with you, to have your patient feel better and feel they have their life back.
And you're going to see those numbers drop. And in light of that, you'll perhaps see the use of illicit drugs drop. I think the newer generation of physicians that are coming out, this is the time to educate them. This is the time to work together with them because they really do need help. I don't think a lot of family doctors like musculoskeletal issues. That's why they send out lots of times to physios, but we're another very strong profession that are stepping up to the plate and we'll be able to help them in enormous ways.
But it's not about us, it's not about them, it's about the patients. The change is going to be seeing the collaboration, working with them in positive ways.
And this lady coined it just so well this morning, "I used to take six of these a day, I'm now periodically taking these, and my ultimate goal is to get off them." And I said, "I'm so incredibly proud of you. You are going in the right direction." And as we speak, I'm going to be sending out a note to her family doctor because that's the most exciting thing that anybody can say. Not only is it exciting to me, it's exciting to the patient. The doctor will be very glad to hear about that too.
So, good luck to everyone.
Thank you, Dr. Scales, for sharing how you co-ordinate care with the prescribing health care professional and one patient's success in reducing her opioid use.
We're taking a break in August so you can enjoy your summer, but we'll be back on September 15 to discuss extended health care trends and how they affect your practice.
I hope you'll join us.