The Weight of Trauma

Dr. Christopher Greene is a guide to Boards and Enforcement Agencies that are navigating the complexities of statutory requirements and professional standards. Certified in auditing, documentation, and compliance, Dr. Greene has assisted State and Federal Agencies in complex cases involving Fraud, Sexual Misconduct and Scope of Practice. Fusing 30 years of clinical experience with unique skills in compliance and auditing, Dr. Greene has been a featured speaker for organizations including the Federation of Chiropractic Licensing Boards (FCLB).

Episode Highlights:

3:32 – Background of Dr. Chris Greene. “I graduated in 1988 and was fortunate I started practice in a time where it was still really a golden age for chiropractors as far as insurance reimbursement and that sort of reality. I had a really fantastic practice for over 20 years. I was fortunate to be a disciple of a guy named Chuck Gibson - many of you know him out there. He played a big role in my life as far as helping me grow my practice and become a chiropractor.  I've always been interested in a multidisciplinary approach to care. The rest of healthcare professionals are really comfortable with dialoguing with us in the framework of being a musculoskeletal specialist and here's one of the reasons why. They're looking all day long for someone to refer their musculoskeletal patients to and, if they want to send me their patients to help with that being the entry point, sign me up. That's caused me to really try to embrace all different licenses out there. As you introduced me, a lot of the emphasis was on this regulatory background that I have, which is really quite extensive. I work with state licensing boards very closely for chiropractic, but also for all different licenses. That helps me to understand that chiropractors may think it's just rough for us, but it's hard for all healthcare providers right now. It's not just us. Another thing I've observed is that a lot of the other healthcare providers are really seeing the wellness approach to care - what we've done in chiropractic forever. They are seeing that as a great place to grow their practices, so it's really important that we hold on to this foothold we have as it relates to being wellness specialists. I don't want to bore people with regulatory stuff, but again, we could talk about the necessity for good documentation, how that plays into reimbursement, why it didn’t happen if it's not documented. I can certainly chime in about the importance of, for the long-haul practitioner, being careful to protect yourself so that you don't end up doing something really stupid that could end up with an allegation of sexual misconduct or something like that. All of that gives you a little background on me.”

14:31 – Recognizing that trauma gets stored in the body. “When we're talking about trauma, there's two different aspects of trauma. You can look at it from the perspective of what we call ACEs, which stands for Adverse Childhood Events. If you just Google that, you can find a lot of information to educate yourself about. There are 10 different questions in this ACEs questionnaire that identify these types of traumas that people are exposed to. The important thing for chiropractors and all healthcare professionals to know is that the majority of patients have a history of trauma. To give you a feel of the numbers from that 10-question questionnaire, 63% of the population have at least one. Of that same questionnaire, almost 20% of the population answer yes to four of them. The HPA axis, hypothalamic pituitary adrenal axis, affects how our brain works and the inflammation in our body. The HPA axis gets adversely affected for people who have a history of trauma. They have chronic inflammatory states, which means that they have a higher rate of cardiovascular disease, diabetes, cholesterol levels, and musculoskeletal conditions. 80% of people with a history of trauma have musculoskeletal conditions. What does that mean for the average chiropractor? The fact of the matter is, in most practices, patients are coming in with some kind of neck or back complaint, so you can rightfully assume that they have a history of trauma. They also have chronic inflammation, which means that they may not respond so great to the chiropractic care just because of the history of inflammation. They probably have a bunch of comorbidities as well. For the astute chiropractor, you want to know about that history of trauma just as far as the probability of it so that you can properly manage that patient. Bringing it back to the question of the multimodal approach to care, trauma-informed approach is well known with pediatricians, dentists, psychologists, psychiatrists, and social workers. If I'm a chiropractor that’s looking to build my practice and was aware of trauma-informed approach, I would definitely be going to the dentist, pediatricians and folks within my community to tell them we do trauma-informed approach in our practice and that I'm looking for other healthcare providers that we can work together to meet the needs of our patients.”

18:15 – Defining trauma. “From the ACEs perspective, that could be sexual trauma, mental illness within the family, drug or alcohol abuse, an incarcerated parent, etc. It really covers quite a broad spectrum of what we might think of as trauma and also what we may not necessarily think of as trauma.”

25:45 – Making the world multi-disciplinary. “Interestingly, some states, and right now the Ohio State Board of Chiropractic Examiners requires their licensees to have, I think two hours of continued education in trauma-informed approach. I believe the North Dakota Board is adding it, and soon it's going to come across all the licensing boards. There are resources for you to become educated about the trauma-informed approach. That's the first step - learning about trauma-informed approach and knowing it well enough that you clearly know what you're talking about. I work regularly with orthopedic surgeons, cardiothoracic surgeons, and a whole lot of different folks that you would think are not that receptive to chiropractors. After a while, they will ask me, ‘from your perspective in your specialty, what do you think about this musculoskeletal condition? And what does that mean?’ They're seeing me as a healthcare provider peer that has a specialty just like they do. They know that in my sandbox, I'm really good at what I do. If I know the trauma-informed approach and the impact on our patients, there's now a door open between the two of us to be able to talk about how we provide patient-centered care. If you're not aware of this, the term patient-centered care is a real buzzword within healthcare providers at large. If you're able to say we focus on patient-centered care, trauma is a big issue, and you want to find providers in the area that you can send your patients to that have a psychiatric need or a dental need or whatever their specialty need is. Then, ask them where they are on trauma-informed approach. They may not know much about it, and that opens the door for you to help them learn about it. You can see how it's a double bang on that one, because if they don't know, you can spend some time with them and share information with them and their staff about trauma-informed approach. That's the way you do that.”

29:19 – Document. Document. Document. “When I do the regulatory stuff with other licenses, nobody likes to document. Nobody. There's a rare oddball like me who gets certification as a documentation expert, but I know I’m an outlier and kind of a freak in that respect. Nobody likes to document, but all healthcare providers' feet are really held to the fire on doing adequate documentation. Honestly, it pisses them off that they feel like chiropractors are getting away with murder because they do crappy notes. If you want to alienate yourself, have bad documentation and send it to them. It doesn't mean that you have to write a novel every time you do a record, but at the same time, you have to know what an evaluation and management service is, what the components of an evaluation and management services are, and what should be there because they're expecting to see that. If it's not there, it lowers your credibility with them simply on the basis of the documentation that you provide.”

32:56 – Do you have homework? “It's pretty straightforward and simple: know how to document that evaluation and management service. For most chiropractors, they would think it's that new patient visit. It is, but there's three components to an evaluation and management service: the history, the physical, and then the medical decision making. The only one that's required now is medical decision making, which sounds weird. It's a foregone conclusion you're going to do the history and physical, but it’s that the emphasis is so much on the medical decision making, which then has three components to itself. The important thing not to get into the nitty-gritty on E/M. Those doctors that you're sending your notes to - that's all they're going to look at is your initial E/M to see what's in your MDM, your medical decision making. If it's not there in the way that everybody else documents, then your notes make no sense to them, and they'll throw them over their shoulder because they don't know what they're looking at. It just starts and ends there. The most critical part, they don't care about your soap notes for the daily visits. They want to see your plan of care - what it is, what your treatment goals are, and the timeframe. If there's a follow-up E/M service, they're going to look for those same things. If you are not documenting in the way I just said or are confused, you’ve got some homework to do.”