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Specialty Referrals

Disclaimer: In November 2005 I was contacted by a health care provider who pointed out that some of my comments about the specific providers below implied that their are inherent abusive characteristics of their profession. After several email exchanges, I realized that it was inappropriate to make negative commentary about one speciality without acknowledging that these shortfalls exist in all professions. Having made that acknowledgement personally to him, I want to state the following:

"After over 2 decades of practice I have come to realize that every healthcare provider specialty has practitioners that abuse the privileges aforded them with their license to practice, including my own profession. While the majority of providers have good intention, my experience has been that, in the absence of oversight, most providers will over treat for financial gain or due to lack of appreciation of "cost vs benefit" considerations. In most states, where personal injury patients are perceived as the golden goose, the magnification of these abuses exists. Therefore, it is imperative to make sure that your clients treat with providers who are known to be respected, reasonable and considerate of all aspects of your clients health and case. It is my opinion that this is best accomplished by making sure that the gatekeeper physician (MD, DO, DC or ND) is of that ilk. That gatekeeper should be a physician you know and trust. The gatekeeper characteristics that make them good managers is that the patient's health care needs always come first but that it is always balanced with the non-medical considerations that define health care access in the United States today." Dr. Steven Shaw 11-21-2005

Orthopedist Surgeon:

The orthopedist is a surgeon who specializes in the medical and surgical management of musculoskeletal disorders. Since their primary income comes from surgical intervention they prefer cases which will ultimately require surgery. I am frequently asked by orthopedists to limit my "back and neck" referrals because the majority do not require surgical intervention and if they did more than likely a orthopedic spine specialist or neurosurgeon would be more appropriate. I have been told by several orthopedists that they limit the number of back and neck cases to less than 5% of the patient load.

From a personal injury perspective the role of the orthopedist is clear. They should receive all referrals from the primary attending physician which involve extremity complaints which may require surgery (knee, shoulder, hand, wrist, foot. etc.). If a spine related referral is requested it should be expected to be given low priority due to the probable non-surgical nature and referred out for a short course in chiropractic intervention or physical therapy.

Unfortunately, the insurance industry has deemed the orthopedist to be the gold standard for soft tissue injuries. Perhaps because of the orthopedist's perceived "insignificance" of the injury. Therefore, when orthopedic referral is made by the primary attending physician the referral should be for the purpose of determining whether orthopedic surgical intervention will be indicated or if continued conservative efforts are appropriate.

Neurologist:

Neurology is the specialty which deals with diseases of the neurologic system. They consider themselves the "cerebral" doctors when compared o the neurosurgeon. Right or wrong they have no inclination to recommend surgery unless absolutely necessary and this benefits the patient. Neurologists spend much of their time working with neurologic diseases like Parkinsons, Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Myasthenia Gravis, etc. They are excellent in identifying the neurologic components of traumatic injuries such as radiculopathies, neuropathies and post concussion syndromes. However, when referring to a neurologist the primary care provider should ask the neurologist to limit their recommendations to their specific area of expertise. If the neurologist feels compelled to comment on other soft tissue components he should suggest that other musculoskeletal components exist and require intervention. The primary care provider should make the decision which methods of intervention are most appropriate.

Physiatrist:

The medical specialty of physical medicine and rehabilitation (PM&R) is the emphasis of the physiatrist. Many physiatrists in institutional settings have areas of specialization such as respiratory rehabilitation, stroke rehabilitation, cardiac rehabilitation, amputation or burn management. Most physiatrists, like chiropractors, have great appreciation of the soft tissue injury. They make accurate assessments based upon thorough examinations. They also regularly perform electrodiagnostic procedures such as electromyography, nerve conduction studies and somatosensory evoked potentials. Revently, many physiatrists have become actively involved in pain management procedures ranging from muscular injections to narcotic management to introperative placement of neurostimulation devices. Their recommendations are directed towards the optimal resolution of the soft tissue complaints. Unfortunately, my experience is that their recommendations are generally excessive. It is not unusual for a physiatrist to order physical therapy which could cost in excess of $4-6,000 on an uncomplicated typical "whiplash" injury. This is not because they are abusive but because they want to offer optimal patient care which can greatly differentiate from necessary care.

The physiatrist is extremely valuable when documenting injuries and can offer the primary physician valuable insight. They should be used regularly with soft tissue injury patients. However, the care recommendations should be referred back to the primary physician so that the appropriateness of the treatment can be considered in conjunction with the medical data and the specific case requirements.

Neuropsychologist

The neuropsychologist is the specialist who can best assess the cognitive functioning of the patient. It is quite common for a patient to suffer psychological consequences secondary to physical trauma. Memory problems, post traumatic stress disorders, sexual dysfunction, attention deficits and other documentable psychological problems must be identified and correlated to the injury. Post traumatic marital, social and professional relationships may be subtly changed and only a specialist with the neuropsychologists education is qualified to objectify these complaints. Of course, organic disease must be ruled out by a neurologist but after medical attention is offered the neuropsychologist is the professional of choice.

Neurosurgeon:

The neurosurgeon can be of great value with cases of documented disc herniation. Herniated discs may or may not require surgical intervention. Any neurosurgeon worth his weight has enough scheduled surgery that only the most severe cases will undergo immediate surgery. Therefore, the neurosurgeon will generally evaluate the patient and refer back for appropriate conservative care. If unsuccessful, he may recommend more aggressive treatment but surgical intervention is reserved for those patients who meet strict criteria.

They are beneficial for the soft tissue injury case because they appreciate that soft tissue injuries can have serious complications which will not benefit from surgery. They usually are conservative in nature and will write supportive reports. Their role is limited in the management of the non-surgical case but their input is well respected in the insurance industry.

Craniomandibular Specialist:

The craniomandibular specialist is usually a dentist who is comfortable in the management of the temporomandibular joint (TMJ) disorders. Not all dentists manage TMJ and not all should. Like any subspecialty it requires additional training and is not for the general dental practitioner. Management of TMJ may involve physical therapy, chiropractic, surgery or the use of prosthetic devices,

The benefit of this specialist is that TMJ disorders are a common result of cervical acceleration/deceleration injuries. While the exact mechanism of injury is not clear the TMJ specialist has the knowledge and expertise to manage this common disorder. If they are familiar with the medicolegal relationship the reports can be of great value in your settlement efforts.

Physical Therapists:

Physical therapist can play a vital role in the management of the soft tissue case. By coordinating care with the gatekeeeper physician they can offer much needed treatment and documentation in the form of treatment notes. They are valuable in optimizing the results achieved by chiropractors when used towards the end of care with an emphasis towards the re-conditioning of deconditioned musculature. This deconditioning is a common sequelae to trauma as the patient will undergo extended periods without physical exertion.

In many states physical therapists have direct access to patients in varying degrees. This reflects a legislative recognition of the improved and more comprehensive education of of physical therapists. As more and more states recognize the autonomy of physical therapists and their ability to self direct care we will see greater solo management by these qualified specialists. At this time, the majority of physical therapy providers acknowledge that direct access is a move in the right direction. They also acknowledge that not all therapists have the education and skills to differentially diagnose patients and rule-out conditions that are not within their diagnostic scope. Until that skill has matured, it is best to have physical therapy care coordinated between the gatekeeper physician and the specific therapy provider.