ACA Guidelines What You Should Know

Supporting the profession by Educating DCs & Sponsoring Cutting Edge Research!

ACA X-RAY GUIDELINES A LOOK INSIDE 

What you should know and what you need to know

ChiroSecure Malpractice Insurance Providing protection since 1991

866-802-4476 www.chirosecure .com

Table of Contents

Dr. Stu Hoffman, ACA Guidelines Part1……………………..……………..3

Dr. Ken Murkowski, ACA Guidelines Who Really Loses?……………..…4

Dr. Studin, Dr. Owens, ACA Guidelines Part 2……………..…………….27

Dr. Clum, Dr. Pedley, Dr. Gatterman, ACA Guidelines Part 3…..………46

Dr. Joe Betz, ACA Guidelines Part 4………………………………………59

ICA Recognizes Radiographic Studies……………………………………70

ICA In Action Special Informational Resource……………………………72

Supporting the profession by Educating DCs & Sponsoring Cutting Edge Research!

ACA X-RAY GUIDELINES & CHOOSING WISELY PART 1 Dr. Stu Hoffman taking the Lead on the guideline issue

ChiroSecure Malpractice Insurance Providing protection since 1991

866-802-4476 www.chirosecure .com

(866) 802-4476

The following is an actual transcript of the ChiroSecure Live Event. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. If you have any questions about the transcript or would like to request any transcripts from our previous shows, feel free to contact us at 866-802-4476. Also note, opinions expressed during these shows are not necessarily those of ChiroSecure. ChiroSecure makes no claims and accepts no responsibility for the legality or enforceability of the contents of this document. It is your responsibility to make sure that the any recommendations by the hosts or their guests are solely theirs and it is your responsibility to make sure your office and staff is in compliance with your state board rules and regulations, and any and all other governing boards, national organizations on the state and federal level you must comply with. Click the image below to visit our Facebook Event Archive to watch any past events you may have missed.

Click here to get future transcripts of all events automatically . Your transcript will begin on the next page.

Dr. Hoffman:

Hi everybody. This is Dr. Stu Hoffman, back again with you with another Facebook Live. I'm happy to be here, and I want to talk to you today about ChiroSecure actually responding to the ACA's Choosing Wisely Guidelines, having to do with X-ray. ChiroSecure has had so many phone calls and emails on this exact topic that it's Jme that we came out and made addiJonal statements about X-ray. ChiroSecure's job, I want you to understand, is really to inform, so doctors can make their own decisions about this issue and do it in a way that offers the doctors the best advice to protect themselves and their paJents, from a risk management perspecJve. Let me tell you what we know. The Choose Wisely Back Pain Guidelines was wriOen in conjuncJon from the ACA and the American Board of Internal Medicine and Consumer Reports, which has never been a friend to chiropractors. On the Choosing Wisely site, under back pain, you can't even find the word chiropracJc, and that the recommendaJons are all of the over-the- counter medicaJons, massage, and, oh, by the way, see your doctor, everything that we hear on all the drug commercials on TV every day. The ACA Choose Wisely Guidelines have been released and are being very publicized. You have to wonder what's behind all of that. The ICA has not endorsed them. In fact, they're not going to, as the ICA have had their own guidelines on X-ray for many, many years. Some state associaJons, they have not endorsed them, and some have even come out with their own guidelines on X- ray, as well. Some doctors actually believe that the ACA is correct, that most paJents should not be X-rayed. I can understand that, based on certain procedures or techniques in the profession. There are some that are not X-ray driven, let's call it, but there are other doctors that absolutely use X-rays for analysis, and they are concerned about the risk, if they conJnue to take them, because of the publicity and the insurance rebuOal to taking X-rays, all of a sudden, already acknowledging these ACA Guidelines that they've actually put out. Let's keep in mind that, in the chiropracJc world, X-rays have been around since the beginning of chiropracJc, and they have always been uJlized from not just a technique perspecJve, but from a pre- and oXen a post-challenge to see what correcJon may have taken place through the chiropracJc care that's being delivered. We have to keep all of that in mind and respect all sides of this in the chiropracJc world, but there are quesJons that absolutely need to be answered. Why would anyone adopt a guideline, for the enJre profession, that doesn't even recommend what has already been proven to be one of the most effecJve drug-free protocols for pain ... chiropracJc? We have this whole opioid epidemic that's killing thousands and thousands and thousands of people, and the medical community is even looking for nondrug answers. We have those answers, and we're now looking at limiJng our ability to analyze a paJent's spine? Why would anyone adopt a guideline wriOen by, or even align themselves with, the two groups, the ABIM and the Consumer Reports, that do not know what we even do?

There's something more to this that we all need to figure out and find out what those answers are. I want to know, do the guidelines even take into account the thrust component of the chiropracJc adjustment? Because I deal with the risk management aspect of it, and if somebody doesn't look and see what's going on, I don't want to get a call for another broken rib or this or that. What about the doctors that use the X-rays as an analysis for being a tool to offer the paJent the greatest outcomes? That's what I always did. What about doctors, whose goal it is to change the biomechanics, restore curves, et cetera, and need X-ray to monitor the effecJveness of the care and, potenJally, the rehab that they offer to the paJents? These are all quesJons that no one has come out and offered answers to. Let's look at some of the potenJal issues. I've already goOen calls from doctors that say that they've goOen messages from insurance carriers that they're not going to pay for their X-rays, because they're now uJlizing the ACA statement on X-rays as a reason to not pay chiropractors for another service. The public may begin to challenge the use of X-rays, as the choosing wisely gains more publicity, since Consumer Reports obviously has a vehicle into the PR machine out there, and the guidelines can become a standard of care legal issue, and that's where I get concerned. Let me tell you what we're going to conJnue to do. We're going to have future shows on this topic, because I think it is incredibly important for the profession to have an actual dialogue, not one side or the other, because there's truth on all ends of this, and we're going to have state representaJves on that may have endorsed or not endorsed the guidelines. I want to have someone from the ICA represent that perspecJve. Someone from the ACA, who hasn't acknowledged the willingness to parJcipate with us yet, but we want to get someone from the ACA to represent them and these guidelines, so that we can make sure that all of our people understand what the perspecJve is on this, since it clearly has not been explained. We want to have DACBRs come on and talk about this from a perspecJve that only they can, because they are the ones reading your X-rays all the Jme. I'll have aOorneys on, to talk about it from a risk management perspecJve. We'll also have experts that use X-ray analysis as part of their treatment protocol. We're going to keep exploring this, because I want to be open to all of our people. We have people that do nothing but network, and those people aren't in disagreement about taking X-rays. We also have people that do, whether it be CBP work or upper cervical work, that is totally dependent on analysis through X-ray. We have to be respecZul to the enJre profession and take on this issue that came out of the blue in conjuncJon with groups that are not our friends, and we have to be a liOle bit curious as to where the moJvaJon is to put this out in the public. We're inviJng all sides on, and we're going to conJnue to explore this. I hope you stay tuned with us, as we conJnue down this path on your behalf. Remember, we're always here to make sure that we help educate the doctors, to Chiropractor Malpractice Insurance ACA Guidelines and Choosing WiselyPage ! of ! 2 3

be able keep their risk low, and we're also here to help educate the profession, as well as the public, because our goal is always to change the public percepJon of chiropracJc and increase the use of chiropracJc through your great services. Let me just end by le[ng you know that, if you haven't already done so, please download our ChiroSecure app. It's free. It's on Google. It's on your Apple phone. Just go to the store. Download it. It's free. You'll get all kinds of risk management topics, different people coming on as guests and providing some incredible material for you. You'll also be noJfied of all of our next shows, and you can watch it and listen right on your smartphone. Like us on Facebook, if you haven't done so already, and, those of you that may not be with us at this Jme, please ... We want you to be with us. We invite you to at least give us an opportunity to demonstrate that we have beOer rates, but, most important, we have the coverage, we have the defenses, and we have the experJse to always be behind you. Go to our website, ChiroSecure.com, and just fill out a quick quote form. It'll take you two minutes, and we will get in touch with you and give you all the informaJon necessary to make an informed choice. Thanks for being with us. Thanks for conJnuing to support us and to follow us. We'll always be there and be that proacJve group that will help guide your decisions, based on informaJon. Thank you.

Chiropractor Malpractice Insurance ACA Guidelines and Choosing WiselyPage ! of ! 3 3

Supporting the profession by Educating DCs & Sponsoring Cutting Edge Research!

ACA's Choosing Wisely X-ray Recommendations Who Really loses? 

Dr. Ken Murkowski ChiroSecure Malpractice Insurance Providing protection since 1991 Dr. Stu Hoffman

866-802-4476 www.chirosecure .com

(866) 802-4476

The following is an actual transcript of the ChiroSecure Live Event. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. If you have any questions about the transcript or would like to request any transcripts from our previous shows, feel free to contact us at 866-802-4476. Also note, opinions expressed during these shows are not necessarily those of ChiroSecure. ChiroSecure makes no claims and accepts no responsibility for the legality or enforceability of the contents of this document. It is your responsibility to make sure that the any recommendations by the hosts or their guests are solely theirs and it is your responsibility to make sure your office and staff is in compliance with your state board rules and regulations, and any and all other governing boards, national organizations on the state and federal level you must comply with. Click the image below to visit our Facebook Event Archive to watch any past events you may have missed.

Click here to get future transcripts of all events automatically . Your transcript will begin on the next page.

Dr. Hoffman:

Hi everybody, Dr. Stu Hoffman, president of ChiroSecure, back with you again with another one of our live shows. So happy to have Dr. Ken Murkowski back with us again. He's done a number of shows with us in the past and he is just full of knowledge and informaDon. I just saw him this weekend at another even around the country and we got to talking about the ACA's new recommendaDon/guidelines on chiropractors taking x-rays that they published in August of this year, August 15. I take excepDon to anyone that is making a recommendaDon that a chiropractor does not need x-rays. Certainly, we know that there are a number of doctors that don't use x-rays as part of their standard pracDce. However, there's always a referral out to a facility. As an example, when I started in pracDce back in 1981, the only place we had to refer out to was the local hospital. Well that was never, ever, ever a good situaDon for us. Now, you have imaging facility on every corner. They want your business. So if you don't have an x-ray, there's no reason to not be able to refer out. I just want to go over these guidelines, because once again, we have to go into the fact that the ACA has taken a poliDcal stance that is not congruent to the tradiDonal pracDce of chiropracDc and I have a problem with that. These guidelines are going to opposed by people like the ICA and we are an affiliate of the ICA. The ICA has had guidelines for many years, including on x-ray. The IFCO, the one chiropracDc group, the ACA is totally outnumbered, but they are the ones that put this out in the public eye and that's going to be problemaDc to all of us in the chiropracDc profession based on their output. I want to just bring on Dr. Ken Murkowski. Hey Ken, how's everything today. It's called "Choosing Wisely," and what's happened is that the ACA has teamed up with the ABIM, which is the American Board of Internal Medicine, which is about 50 different medical boards. They have about 350 members and they set guidelines for all these medical situaDons. Well, apparently, the ACA through a couple of their officers have, were approached by ABIM, or they approached them, I don't know which one. I haven't been able to find that out and they came up with these five new guidelines and one of the one that has the most reacDon in the last 16 days is the do not obtain spinal imaging for paDents with acute low back pain during six weeks a\er onset in the absence of red flags. I guess if we take that iniDal statement, we really do have to look at it what I call with the magic prism and that is turn that magic prism around and look at it from different aspects to see how this actually came about. I guess what I'll lead off with is that since they did come from The American Board of Internal Medicine, when they proposed these things or they had their input, they're talking about how a medical physician, which would approach a paDent with low back pain. Of course, we all know the standards for that is of course pain killers, Good, Stu, how are you? Good. I wanted to see if we can start perhaps by addressing, what's actually in the ACAs document? Where did it come from?

Dr. Murkowski:

Dr. Hoffman:

Dr. Murkowski:

Chiropractor Malpractice Insurance Dr. Ken Murkowski The ACA X-ray Gui... Page ! of ! 1 9

muscle relaxers, maybe some restricDon of duDes and ABLs, maybe bedrest, possibly even some physical therapy and that's normally the course of care for six weeks. Now if we stop, and we turn the magic prism for a chiropracDc doctor, a doctor of chiropracDc, if a paDent comes in with low back pain, there are of course guidelines that everyone recognizes, about the examinaDon, the case history, and everything, and the one thing that I think a lot of people haven't even brought up yet is what the one thing I definitely want to bring up right away is when a doctor of chiropracDc has a paDent who's new that's coming in with severe low back pain and it's acute and you're going to plan on doing a thrust into that area, you be`er know what's in that area if you're gonna do a thrust. Doing a thrust is totally different than having some paDent lay in bed on drugs. I totally agree and that may, is one of the reasons that we have you on today and we want to talk about this because it affects our ability to defend a doctor when it comes to malpracDce. But one of the things that you pointed out was you know, in the medical model, communicaDng what makes sense from an x-ray or not, means nothing. From a chiropracDc point of view, even going back to 1993 when the AHCPR guidelines for low back pain were published by the federal government, there were only two things that were indicated to have worked for low back pain, chiropracDc adjustments and exercise. No medical procedure showed any effecDveness whatsoever as I recall, and here we are having the ACA teaming up with the medical community that has nothing that has been successful in this area to determine what a chiropractor should do or shouldn't do in their pracDce. What about even the doctors that are upper cervical doctors? They need those x-rays to get an exact line of drive and to have a pre and post x-ray, not even just a beginning point. As you said, you're gonna put a thrust in. You know to me, I prefer to have that informaDon of what is going on before I actually take care of somebody, so I think you're right on and all of this comes back to, you know are you now going to listen to a ridiculous guidelines like this or arDficial guideline and put yourself in jeopardy and at risk for a potenDal malpracDce. Well, I don't think anyone obviously is a fan of malpracDce and the one thing I think that we all need to do on this parDcular issue is sort of again, step back and look at the magic prism. You know, we've had, we have so many different techniques, and each technique has its own requirements. To me, the issue of x- ray should be le\ up to the individual doctor of chiropracDc. It depends on their technique, it depends on the paDent's complaints, it depends definitely what the doctor finds in the examinaDon and again, there are so many variables here and like you menDoned, the x-ray line analysis. I don't care if you pracDce blair, gonstead, upper cervical whatever, chiropracDc is based for over 100 years on being specific. Which means, you're supposed to do a specific CMT, an adjustment.

Dr. Hoffman:

Dr. Murkowski:

What really someDmes comes up in malpracDce cases is when there isn't a proper workup, there may not be a proper work up. There may not even be x- rays and somebody's going in there and doing manipulaDon on vertebrae going Chiropractor Malpractice Insurance Dr. Ken Murkowski The ACA X-ray Gui... Page ! of ! 2 9

right to le\, le\ to right, with what, like master rotaries, and we all know about those from school and then they're expecDng that there's gonna be no negaDve results. It could be posiDve, it could be negaDve, but it really depends on what basically is taking place inside the spine and to go in there without knowing what's in there, like I said, if you're gonna thrust, you want to know what's there and we have guidelines in place and all the colleges, they have their guidelines for their interns. The ICA has guidelines, the people that teach technique seminars. Gonstead has their guidelines. There are so many guidelines going around, to me, this was sort of a unique situaDon that the ACA would team up with the American Board of Internal Medicine and try to not even take into consideraDon the difference between doing something passive for the paDent like rest and drugs as opposed to doing something acDve where you're gonna thrust into an area that you're dealing with the eight physical components of [inaudible 00:09:24], which could be the disc, the altered biomechanical, maybe the spine is severely rotated from a trauma. Maybe there's a problem with imbalance, neurologically going into the muscle system. You want to know what's in there before you start thrusDng. You know, I kind of think that this may be a situaDon where the ACA is trying to regain some relevance in the profession because you have the drug people now taking their place all the way on one side of the profession. On the other end are people that are pro subluxaDon, again whether it be the ICA, one chiropracDc, the IFCO all on the other end, they're looking for a voice once again and this may be what it is. Not only did they team up with ABIM, but it was also a conglomeraDon with consumer reports and consumer reports has never been a friend to the chiropracDc profession so this is right up their alley to try to limit us into more of a therapeuDc approach rather than a doctor of chiropracDc approach analyzing and correcDng the verDcil subluxaDon that we find through someone's spine and I think that is problemaDc that we have groups working on behalf of these outside groups that are not supporDve of what we do. Well the other thing I, again, like I said, I always am respeciul to everyone's philosophical beliefs. I'm respeciul to whatever technique they use. I'm respeciul to you know however they do case management, but again, the one thing that brings [inaudible 00:11:21] under one roof is we're sDll all doctors of chiropracDc, we sDll all believe in our primary you know tenets that there is a philosophy, a science and an art, we know that the causes of subluxaDon in the chiropracDc profession [inaudible 00:11:37] traumas, autosuggesDons, toxins, and of course spinal problems, so if we even take the four basic things that we have in our history for over 100 years, traumas. Well, nurse trauma, that's another reason to consider x-rays.

Dr. Hoffman:

Dr. Murkowski:

When you talk about autosuggesDons, you're talking about stress, of course we know that stress today is gonna cause altered biomechanical states due to the chemical imbalances, that's where the chemical components of subluxaDon, so that's gonna make the spine and again, not in its proper posiDon so again, I think leaving it up to the individual pracDDoner, depending on his or her technique, Chiropractor Malpractice Insurance Dr. Ken Murkowski The ACA X-ray Gui... Page ! of ! 3 9

depending on his or her way to manage a paDent is the thing that's important, and again we could always go back on one very basic thing. If that parDcular pracDDoner doesn't do something good, then always, there is that issue of malpracDce, which we're gonna have to deal with in another system. The other thing I looked at when I first looked at these guidelines is again, I think I shared with you early, since Sunday I've had like over 50 calls on this. I've had over 100 different text and emails, I won't even tell you how many student contacts I've had over this from the different colleges, but the one thing is, anyDme guidelines like this come out, you also have to step back and look at the business aspect of this. What does that mean? That means that once the third party industry sees something like this, there may be another push now to either reduce or try to take away another thing that they pay chiropracDc for, which right now is x-ray. When we have other third party companies uDlizing chiropractors who have held naDonal posiDons before, I mean that concerns me. I mean we're looking now not only what's good for the paDent, but now we're looking in how that's gonna affect chiropracDc and how we run our offices from a business point of view, so the way I always explain it is in chiropracDc, there's two hands. The right hand is love and service, and the le\ hand is you know, business and legal. They come close, just don't get them confused. But in this issue, they are gonna be cross referenced quite a bit I think, because of this stance. You menDoned you know, these insurance, these, having an excuse basically to not pay for x-ray now and you know, I know personally, you know one example would be Aetna, who's hired one of the hierarchy of the ACA, what a coincidence and what a coincidence in Dming. I want to shi\ from that just a li`le bit. You know, you know the god of chiropracDc x-rays, [Terry Yochum 00:14:28], and you know, you menDoned the ICA guidelines before. Historically, where do these guidelines fit in, forgekng what the ACA just tried to do the profession, where do the tradiDonal guidelines show up for the doctors to be able to really benefit the paDent because isn't that what it's really all about. What's in the best interest of the paDent? I think that should be the primary focus on every visit by every chiropractor is what is best for the paDent. In answer to your quesDon or statement, this past weekend I was in a program with both Dr. Terry Yochum and Dr. Alisha Yochum and we did discuss this whole situaDon on these ACA guides and choosing wisely. The guidelines that have been in effect at the chiropracDc colleges. Again, each chiropracDc colleges, they teach li`le nuances and differences on techniques.

Dr. Hoffman:

Dr. Murkowski:

I think the guidelines that are generally accepted throughout the profession, the guidelines that the ICA has in effect, I don't know if anyone's really taken the Dme to read the ICA guidelines on x-ray. There's over 20 different items. I believe it's, I think it's 27 and they have guidelines like the child is under 10 years old, I mean, these guidelines are enough or should affect any chiropractor, it can affect any chiropractor because if you take those guidelines, which are so, so Chiropractor Malpractice Insurance Dr. Ken Murkowski The ACA X-ray Gui... Page ! of ! 4 9

wri`en carefully that it affects anybody, doesn't ma`er what technique, doesn't ma`er what your philosophy is, it is general, it's not an ACA versus an ICA. These guidelines were put together for the general doctor of chiropracDc and if we have to look at it you know staDsDcally or logically, there's the majority of chiropractors don't belong to associaDons. Maybe their state associaDon where they pracDce, which is very important, but when you talk about guidelines from one organizaDon or another, those should not impede anybody in their actual pracDce in my opinion as how to take care of the paDent. The paDent is the primary concern all the Dme. I'm in total agreement with you and my concern is that what the ACA is pukng out there is not only pukng the doctor at risk, but it's also pukng the paDent at risk because if the doctor doesn't have the appropriate informaDon, then the paDent ulDmately suffers and that's always a concern you know to me. I come from the malpracDce risk management perspecDve, but you know, like you said and we agree, you know it's ulDmately about the paDent and I don't understand why anyone would put out something that doesn't really address what's in the best interest of the paDent. What could possibly be a raDonal to not take an x- ray. We know that there's no business incenDve to not take it, there's not real radiaDon consideraDon when every Dme you sniffle you go to the hospital and they'll take an MRI or a CAT scan or whatever, we're talking a basic, simple, chiropracDc x-ray here. I don't see any risk versus all the reward. I have a couple I guess ideas or couple of hypotheses. First I want to say that I know people in the ICA, I know people in the ACA, I know people that don't belong to any chiropracDc organizaDon and I know, there are good people in everything. The ACA, I've had conversaDons with a number of ACA people in the last few days, including some of their officers, not everybody in the ACA is happy with these guidelines. There's good people all over. I think one of the quesDons you brought up is the reason or how this came about again, I don't know if this is gonna be proven to be fact, but this is my general hypotheses. Again, we have to turn the magic prism. First of all, many new doctors, the millennials coming out have high student loans. So in some cases, it actually prohibits them from having x-ray in their office right away. But that's where the referrals come in like you menDoned. The other thing is that a lot of the millennials have these different pracDce management groups that talk about you have to now in order to survive, you have to have an integraDve pracDce. Well, these guidelines coming from the American Board of Internal Medicine is sort of a precursor to having the DCs and MDs in one locaDon. It's an integraDve type of pracDce and I've seen modern chiropracDc offices. I was just at one not too many weeks ago where the chiropracDc office, if you walk right across the hall, you're into the vein clinic. You went right down the hall, you're into the neurosurgery clinic. It's all under one roof.

Dr. Hoffman:

Dr. Murkowski:

Again, for a new pracDDoner, I think that's very appeDzing. I think that they think that's the way to go in the future. I'm not saying it isn't, but I'm saying that the most important thing again, I keep hammering is what's good for the paDent. Chiropractor Malpractice Insurance Dr. Ken Murkowski The ACA X-ray Gui... Page ! of ! 5 9

But just because you have a new pracDce and you have a high student loan doesn't mean that you don't do what's necessary for the paDent, whether it be in office or referral. Right on. You know, I take a stand for what I think is right, whether it's best for me from a business perspecDve or not and I would just say to our enDre audience, that you know, these are things that cause us to want to take a stand and put our money where our mouth is. You know, there are great people that are members of the ACA. You pointed that out and I want to highlight that because I have a lot of friends that may be members there as well. There are groups that you should be supporDng. First and foremost is the ICA. The ICA already has guidelines and I personally will support those. But you also have you know, one chiropracDc, even the IFCO I'm gonna be meeDng with Jack [Borla 00:21:24] next week while I'm speaking up at one of the colleges. All of these groups need resources to be able to do the things that the ACA is out there doing by compromising in my opinion, what we do as a chiropractor. I'm not looking for adding drugs into a profession that's a drug less profession or taking away our tools. If you're not uDlizing x-ray, God bless you. Maybe you're a network doctor and that doesn't fit, you do more nutriDon, whatever. As Dr. Murkowski said, if you're dealing with high velocity thrust, you certainly should consider what you're actually thrusDng into and or if it's a personal injury situaDon, you may want to consider what the heck you have going on there. Even from a documentaDon point of view, a pre and potenDally a post, which is how I always pracDced. Ken, is there anything else you want to add to this in terms of understanding some of the raDonal for x-ray? I think what I would suggest to our audience today is to definitely take the Dme to go and look at the guidelines from basically the college you graduated from, then go and if you're into a parDcular two, three, four techniques in your office, look at what those technique instructors are saying their guidelines are, and then go and look at the guidelines that have been in existence for literally years from the ICA on their x-ray, which basically, they're not just the ICA guidelines, they've submi`ed them on a naDonal level, which has been accepted and make your decision for yourself. Again, it's up to the pracDcing doctor when to x-ray. It shouldn't be based on some poliDcal organizaDon, whether it be ACA or ICA, but at least look at the guidelines and be objecDve to how that fits into your type of pracDce. If you have, like you menDoned, the high PI pracDce, you would be hard pressed to take care of any PI paDent who's injured and go into any kind of liDgaDon without x-ray evidence. Again, in that parDcular sense, I can't tell you how many a`orneys for those type of paDents have said, no x-rays, no defense. How could you defend something that you didn't examine and x-ray thoroughly and then say there's injuries or that they're paDent may have permanent spinal impairment.

Dr. Hoffman:

Dr. Murkowski:

Chiropractor Malpractice Insurance Dr. Ken Murkowski The ACA X-ray Gui... Page ! of ! 6 9

There's so many things and this past weekend, Dr. Yochum, Terry and I have been friends for over 25 years, and we talked about the difference even now today with the, not just plain images, but the MRIs, the sDr MRIs, I mean there's so many different things available for chiropracDc today that would give us more knowledge to give be`er care, and that's the ulDmate thing, the best care for the paDent. I agree. But, there's also a contradicDon you know based on our Dmes. We have an opiod epidemic, and the medical community has no answer to it. Their only answer is let's give them a different drug to hopefully take them off of another drug. We are a natural alternaDve when it comes to all of these people that are have been in pain for so very long and now we have the ACA trying to De up our hands in gekng our job done for these paDents and isn't that a contradicDon to the paDent themselves? I'd have to say yes because again, one of the things that I did this past weekend, was for the, at the foot levelers summit meeDng and that was one of the biggest topics we talked about how the chiropracDc treatment plan and the chiropracDc rehab plan is one of the key components today to help address the opiod epidemic that we have and I think if a person has been on those opioids for so long, which is now affecDve not only their bowels, their digesDon, but all these other things, swapping out drugs as you menDoned, is not gonna help at all, gekng to the root cause of the problems. You know before, when I went to school, we used to have these li`le different things. DC stood for doctor of caring. DC stood for doctor of cause. It seems today that DC stands today for doctor of compromise or doctor of consensus. I mean, I don't think anybody runs their office of consensus. It's whatever the doctor says, so I think we need to have what I call an aktude adjustment here. Keep in mind what's good for the paDent and the doctor must do what's right in their office. Why? Because you have to also have an obligaDon to protect yourself. Yeah, and you know, I always have to wonder, you know, just having been in pracDce for so very long, how does somebody really know if there's an underlying issue without taking an x-ray. You know, I wasn't one of those doctors that wanted to find disease process, but I wanted to know everything I could know about that spine so that I can be the master to uDlize my hands to help correct that subluxaDon and allow that person to express their health be`er and more vibrant and have a be`er life as a result of that. I feel like this is potenDally another a`empt to even squish the tradiDon, the philosophy, not just tying up your hands. You know, I'm not one of those people that sit back quietly and just let these things happen, that's why we're doing the show. We want people to know what's going on out there and I think we'll even for those people that subscribe that we send out transcript to this, we'll even include on the ACA arDcle as well as maybe the ICA guidelines so that people can actually see what's going on out there because we need to support the areas that support us as doctors of chiropracDc.

Dr. Hoffman:

Dr. Murkowski:

Dr. Hoffman:

Chiropractor Malpractice Insurance Dr. Ken Murkowski The ACA X-ray Gui... Page ! of ! 7 9

Dr. Murkowski:

I think that if ChiroSecure did send out not just the ACA statement, but just the guidelines that we discussed and then the doctors again go back to the chiropracDc college or university that they graduated from and check their, I think almost every chiropractor today is gonna be very, very surprised that those guidelines are so inclusive to support any type of technique that you choose in your office plus whatever your personal philosophical belief plus again, it takes into consideraDon protecDng yourself as the doctor and of course doing a good service for the paDent. So if you guys will do that, I can't think of anything I could suggest to you that would be be`er served for our community than looking at the guidelines and looking at the five things from the ACA and then let the doctors make their decisions. Well thanks, Dr. Murkowski. Always a pleasure having you with us. You've been a good friend for so many years. I do want to you know, encourage our doctors to take acDon, make your voice heard at the ACA, but you can't make it heard any louder than by joining the ICA, One ChiropracDc, IFCL, join them all. They all need your help and support. ChiroSecure has always been a resource for our doctors. We'll maintain that posture, we're been a leader, we're going to maintain being the leader in gekng informaDon out to the doctors relevant to them and their pracDce and keeping their risk as minimal as possible. We pracDce the safest healthcare system in the enDre world as far as I'm concerned and my job is always defending those doctors that get approached with [inaudible 00:30:27] counters that so I want to be there for our doctors. ChiroSecure is behind you and if you're not with us, certainly we want you to support what we do in our mission as well. I want the doctors that are with us, go to the ChiroSecure website, fill out a quick quote form or an applicaDon and get on board with us. It's Dme to stop being wishy washy in this profession. We have too many people trying to stop us from what we do and I don't appreciate it and I'm gonna keep pukng my voice out there to support the chiropractors that are pracDcing chiropracDc and we are going to maintain that at ChiroSecure and be your resource. I just wanted to reiterate for the record that this is not an ACA or an ICA situaDon. It doesn't ma`er whether you're ACA member or an ICA member, or no CA member, what ma`ers here is that the doctors do what's right for the paDent with good, safe quality care and the doctors protect themselves and x- ray when necessary and basically, the most important thing is always do what's right for the paDent. It has nothing to do right now in my opinion whether you're AC or IC, let's do what's right for the right reason. I want to be clear that this is not AC versus ICA. I am ICA, but at the same Dme, I already indicated there are some really good people within the ACA membership. This is a poliDcal issue however and even if you're an ACA member, this should get you Dcked off and you should make your voice heard to the ACA. But, we all want what's best for the paDent and what's going to reduce the risk for the doctor so please be clear about that. I want to thank you for parDcipaDng with us today and thanks everyone for being so supporDve of ChiroSecure. Thank you.

Dr. Hoffman:

Dr. Murkowski:

Dr. Hoffman:

Chiropractor Malpractice Insurance Dr. Ken Murkowski The ACA X-ray Gui... Page ! of ! 8 9

Dr. Murkowski:

Thank you.

Chiropractor Malpractice Insurance Dr. Ken Murkowski The ACA X-ray Gui... Page ! of ! 9 9

Supporting the profession by Educating DCs & Sponsoring Cutting Edge Research!

ACA X-RAY GUIDELINES & CHOOSING WISELY PART 2 

Dr. Mark Studin

Dr. Wm. Owens

Dr. Stu Hoffman

ChiroSecure Malpractice Insurance Providing protection since 1991

866-802-4476 www.chirosecure .com

(866) 802-4476

The following is an actual transcript of the ChiroSecure Live Event. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. If you have any questions about the transcript or would like to request any transcripts from our previous shows, feel free to contact us at 866-802-4476. Also note, opinions expressed during these shows are not necessarily those of ChiroSecure. ChiroSecure makes no claims and accepts no responsibility for the legality or enforceability of the contents of this document. It is your responsibility to make sure that the any recommendations by the hosts or their guests are solely theirs and it is your responsibility to make sure your office and staff is in compliance with your state board rules and regulations, and any and all other governing boards, national organizations on the state and federal level you must comply with. Click the image below to visit our Facebook Event Archive to watch any past events you may have missed.

Click here to get future transcripts of all events automatically . Your transcript will begin on the next page.

Dr. Hoffman:

Hi everybody, Dr. Stu Hoffman, President of ChiroSecure, back again with another Facebook Live event for you. I think that this issue is so important that we need to get a rounded approach from around the enCre chiropracCc profession on this ACA x-ray issue. And we've invited the ACA to parCcipate with us, to give us their view on how they came up with their stance on choice, but they've declined. At this point we haven't been able to get them on. However, we're going to sCll conCnue to educate our doctors all around this enCre profession on this subject, and today I've got someone that's been a friend for so, so many years, Dr. Mark Studin from New York. And I've known Mark since ... I don't know if he was just a student or I was, one or the other, it goes back that far that someCmes it gets a liMle bit fuzzy. But Dr. Mark has done so many things in the chiropracCc profession. And he is an adjunct professor at the University of Bridgeport, the College of ChiropracCc. But he has also been in joint partnership with the State University of New York at Buffalo, their School of Medicine and Biomedical Sciences. We also have Dr. Bill Owens, adjunct assistant professor State of New York at Buffalo, again, the School of Medicine of Biomedical Sciences. He has done a ton as well. And both of these gentlemen have been involved in numerous schools, their conCnuing educaCon programs and they've done a number of things to educate doctors on MRI studies and x-ray and all of that, which is why I wanted to have them on today. So, first and foremost, I want to thank both of you gentlemen for parCcipaCng with us and helping us to get informaCon out to the chiropracCc community. So, welcome, and I want to just say that Dr. Owens and Dr. Studin released an arCcle on October 13th that basically said, should chiropracCc follow the American ChiropracCc AssociaCon/American Board of Internal Medicine's recommendaCons on x-ray? So, Mark, can you help bring us in to your arCcle a liMle bit, tell us why you felt the need to even put that arCcle out there to start with? Well first too, thank you for having both Dr. Owens and myself and we really ... and I want to make this very clear, we're not making a poliCcal statement, because truthfully I think the ACA has done wonderful things through the years. Really great things. And so has the ICA. And my only poliCcal statement is there should be one CA where we all work under one umbrella. So that's my poliCcal statement. So, other than that, when we look at x-ray ... I mean, it's really not a poliCcal issue, it's a chiropracCc issue and it's not so much a referendum against that arCcle, even though I strongly disagree with a recommendaCon of no x-ray with their limited guidelines. It's really what is the uClizaCon of x-ray for in chiropracCc and one of the problems is, is that we've goMen away from mechanical spine issues and a whole spine model. And that's a problem. We're not just looking for cancers and tumors and infecCons or fractures. We're looking at a mechanical scenario in a whole spine model.

Dr. Studin:

Now, Dr. Owens, who I've worked with extensively over the last decade ... Bill is a graduate of the Royal College of Surgeons educaConal program. The first and only chiropractor in the world, and this, I think, is a 500 year old program, Bill?

Dr. Owens:

Like 1353, yeah, it gets absurd.

Dr. Studin:

So it's a 600 year program and we live in the world of educaCon and the chiropracCc educaCon at the highest level. And we do work the State University of New York of Buffalo School of Medicine. Bill actually runs clinical rotaCons through the Family Medicine Department and the Neurology Department. But we also have done ... we've both been published in biomechanical stuff. And we felt that they're just missing the huge amount. And then if you include the American Board of Internal Medicine and their guidelines, where's their training on mechanical issues? So, Bill, maybe you should pick it up from here, talk a liMle bit about the whole spine mechanical model and where you feel that that recommendaCon really is efficient and what's needed in the contemporary chiropracCc pracCce. That's a really good quesCon. And for chiropracCc to take a leadership role in spine, we have to fill a niche in the greater healthcare system that really isn't already filled at a high level. And to the medical community, that niche is the mechanical spine pain or ... someCmes they call it non-specific. And we know that the objecCficaCon of what we're treaCng is really the goal of any physical examinaCon. Whether it's heart disease or diabetes, whatever it may be. And for chiropractors, to be able to objecCfy what we're going, how we're adjusCng, is a really, really criCcal component. So when I teach third and fourth year med students, or residents rotate through my pracCce, the concept of us focusing on the biomechanics of not just the single region of the spine, but of the whole spine in general, is something that is working, it's worked for us since 1895. And it's something that the greater healthcare system is actually looking for. But, in order to do that, we have to consider how we look for these problems. How do we know where to adjust, parCcularly in paCents that are in spinal. So, a lot of this whole spine model that Dr. Studin menConed, is really being published in the neurosurgical and the orthopedic surgical journals. And what they're finding is that one of the most common reasons that spine surgery fails, parCcularly scoliosis surgery, is that there's a biomechanical abnormality in an adjacent region of the spine. And most of the research is saying why did low back surgery fail? Well, because there was a loss of cervical lordosis or there was a loss of coupling moCon in the spine. So, not only is primary care realizing mechanical spine pain needs a definiCon and a leadership ... a profession to lead it's management, the surgical people are as well. And that's what Mark and I started talking about with this whole x-ray guidelines thing. That the mechanical component is just as important as the pathological component.

Dr. Owens:

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Dr. Hoffman:

That's great, Mark, I just want to add in to that, that first of all, I'm glad that you gave a comprehensive answer to that, Bill, because so many of our doctors would say, "Well, you know, I'm not a pain doctor, I'm not a structure doctor specifically. I fix subluxaCons or I reduce them and allow the body to express itself through innate, blah, blah, blah." We really have a wide ranging profession. And I said on a previous show that we have some network doctors that really may not care as much about this as opposed to an upper cervical doctor or maybe a full spine doctor, a Gonstead doctor or anyone else that does appreciate this. So, let me just go to your arCcle for a second and just start with that. One second, there are two issues. Number one, just to piggy back upon what Bill said and to segue in to what you said. ChiropracCc started, and I've been in the game for 37 years and you and I have known each other for a long, long, long, long Cme. When we started, everything was full spine. And then everything went to regionally. And then all of the sudden, it's regional compartmentalizaCon. Medicine, 37 years ago, was regional. And what's happening is, chiropracCc has now gone from full spine down to regional, down to why do you even image the region? Where medicine has gone from regional and based upon their more extensive research than us, than chiropracCc, because they have money, a lot more money. They're realizing that the full spine model is important. And when you're a surgeon fusing, and you can't overlook that chiropracCcally, okay. Because when a surgeon fuses a spine there's failed spinal surgery, not because of the area they did, but because the areas above or below reacted poorly, because it wasn't fused in a proper anatomical ad juxtaposiCon with the ... it wasn't the right angle. And they were guessing. And a lot of them are sCll guessing and they don't want to guess anymore. So, here's my answer to a lot of those doctors who are ... and I'm not going to use a technique name, but those doctors who adjust. Are you adjusCng the primary lesion or are you adjusCng compensaCon? How do you know? Most don't know. The spine is organized in a certain way. And you have to understand where those stressors, where the organizaCon is. And you're job isn't just to get a [inaudible 00:10:44] ... here's the problem with chiropracCc, it works too well. Symptoms go away so everybody gets beMer really fast, but are you making a structural correcCon that's lasCng? So and here's my challenge and a direct answer to your quesCon, Stu. And when I teach, and Bill and myself are actually inCmately involved with three chiropracCc colleges now that we hope we're making some posiCve influence, and there's a lot of debate even within those schools, we work extensively in two medical schools. But here's my challenge to every doctor listening to this. You make an accurate diagnosis, prognosis and treatment plan prior to laying on your hands. Because you're first credo is doctor, do no harm. Here it is, ready? "I Stu, so if I can- Yeah, go ahead Mark.

Dr. Studin:

Dr. Hoffman:

Dr. Studin:

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know I can get this person well, I know I can get ... " Come on. Those days are long over. They're just gone. Diagnosis, what's the diagnosis? Can I help you? What is the treatment plan, then render care. The days of having someone on the hood of your car at the beach, laying them down and adjusCng every stranger that walks by, preMy cool when you're first out of school and you haven't hurt anybody. But over Cme ... and listen, I am guilty of everything that I am communicaCng with you right now. I've gone the gamut of closing my eyes and being the dogmaCst and knowing I can help them get well. But when I consult, and Bill consults doctors as we do in 47 states, and we see things like tumors, and osteomyeliCs and spinal cord issues, and my god, thank god I didn't adjust this person. They'd be crippled for the rest of their life. When you hurt that one person, even if it's one of 10,000, your license is done. That person's life is over. Doctor, do no harm. Diagnosis- Well, Mark, I agree and that's part of the reason that we have these shows. Because we're concerned about making sure we reduce the risk for our doctors. So, let me just get in to your arCcle for a minute. Because in the beginning of the arCcle, you state that the ACA is opining and sehng precedent that can be used against individual pracCConers or even the enCre profession. Granted, the underlying tone is to prevent unnecessary exposure to ionizing radiaCon, but at what cost to paCent care? I mean, let's talk about this in terms of the cost to paCent care based on these guidelines. Well, the dogma and the rhetoric is very interesCng because none of this discussion ... and I don't want to sit here and sound like, you know, my philosophical posiCon is allopathic or [ergomeCc 00:13:37]. In fact, the longer that I have [inaudible 00:13:40] ... specialty of medical doctors, the more focused I've become on chiropracCc. And the rhetoric that's coming out, as far as ionizing radiaCon is that number one, and again it's rhetoric, that radiaCon is cumulaCve. That as I take more and more x-rays, I'm going to get more and more ... I'm going to get hurt more, right? It's going to cause harm. That discussion is not even present at anywhere in medical specialty, at any level. It's certainly not discussed at that level in the radiology, the neuroradiology community. And in fact, there's only one main study that had any sort of populaCon based view, and that was all the way back to the first bomb drop in Hiroshima. And that's the populaCon that we're sCll working off of. There hasn't been any modernized influence. So to lead with something that's decepCve, such as well, we're hurCng people by taking an x-ray, is almost really a nonstarter, because we seem to be the profession that's the most concerned about that. And no other ones are, at least in my experience, I don't know if that's what you experience too, Mark. Yeah, as a maMer of fact, the radiologists and urologists, when they so fluoro exams on a paCent, don't even want to let imprints anymore. Because there is zero evidence, there has never been ... for diagnosCc imaging, there's just no evidence. There was scant evidence in one remote case that was recorded Bill, why don't you handle the ionizing radiaCon dogma.

Dr. Hoffman:

Dr. Studin:

Dr. Owens:

Dr. Studin:

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