NPs working with chiropractors

[mystcnurse]

I am wondering if there are any NPs who are working with chiropractors - and what your experiences have been like. Do you feel that you are respected? Do you get the training that you need? What about continuing education? Benefits and salary? Any information would be helpful!

[mystcnurse, MSN, APRN, NP]

Chiropractic was founded by DD Palmer in 1895 in Davenport, Iowa. He described himself as a "magnetic healer." Palmer claimed to have learned Chiropractic manipulation from a spirit during a sèance.

Should be 'nuff said, but wait, there's more!

Below are the first 5 articles in my 30 second search. I could link another 3,332 of you like. The conclusion is that at best, there is no outcome difference between chiropractic manipulation and massage. At worst it is highly dangerous in practice, both due to direct risk and the fact that many patents are seeing a chiropractic provider in lieu of a qualified professional.

It is nothing more than sham pseudoscience and any self respecting clinician should have nothing to do with them.

A Cochrane review of combined chiropractic interventions for low-ba... - PubMed - NCBI

Vertebral artery dissection and cerebellar infarction following chiropractic manipulation

A randomized controlled trial comparing 2 types of spinal manipulat... - PubMed - NCBI

Adverse events after manual therapy among patients seeking care for... - PubMed - NCBI

A review of the evidence for the effectiveness, safety, and cost of... - PubMed - NCBI

Bluedevil,

During your thirty second search, did you actually read any of the articles? Because none of them actually say that chiropractic manipulation does not work. The first article you linked to actually says that in the short and possibly intermediate term, there is improvement - compared to "other" modalities of treatment, although I am unclear as to what those modalities are.... I am having to assume drug therapy (which, although helpful for pain, is not without risks, including drug dependence, and in older adults, falls and other negative effects).

The second article you quote is regarding/describing ONE case of VAD - that was attributed to chiropractic manipulation. The other causes, which are more frequent, include minor trauma, yoga, cervical injury including minor cervical fractures, etc, AND inproper guidewire placement during other procedures. The fact is, that it is often, if not commonly, misdiagnosed by "qualified medical providers". MANY conditions are, and there are huge complications associated with many medical treatments, especially drugs of all kinds - and misdiagnoses of this and other conditions is often the norm. Have you looked at the data/research associated with the use of epidural steroid injections (which are commonly provided by "qualified medical professionals")?

The third article has this conclusion: "Participants who received either form of SM (spinal manipulation) had improvements on average in functional status ranging from 1 to 2.2 over those who received MCMC (minimally conservative medical care). So it was basically comparing TYPES of spinal manipulation and medical care. This article has a positive association with SM and back pain.

The forth article concludes: "Adverse events after manual therapy (massage) are common and transient. Excluding spinal manipulation or stretching do not affect the occurrence of adverse events. The most common adverse event is soreness in the muscles. Women report more adverse events than men." I honestly do not see how this article contributes to your argument that chiropractic care is unsafe or ineffective.

The last article you linked to says very little - but it begins by saying that conventional treatments are basically ineffective. The actual conclusion states: "Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy."

So are there plenty of articles out there disputing the use of chiropractic adjustments? Yes, I am sure there are. But I can find just as many disputing the use of many drugs, procedures, etc. I can find articles that list all kinds of negative outcomes that are associated with conventional medical treatment, as well. And, I can find articles that show that chiropractic adjustments are effective, although, from my point of view as a patient and provider, they are certainly not for everyone. At the same time, I can tell you that I pay my chiropractor $35.00 for a visit, and now see him no more than once a month. A visit to a specialist, even with insurance is at least a $50.00 co-pay. And from my patients' perspectives, collectively, they are throwing their money down the drain - for the most part when seeing pain management specialists.

However, I can say this: Below is my x-ray. Despite many emergency room and MD visits, including two pregancies that, other than back pain, were without complications, the scoliosis present was never once addressed. In fact, I did not find out about it until about 15 years ago when I was able to see my own x-ray during a work up for diverticulosis (which is common in people with scoliosis, from my anecdotal experience). I was never provided any treatment options for long term relief - only drugs, which I cannot tolerate. I have seen a "bad" chiropractor in the past, but since recieving regular care from a skillful and professional chiropractor - who genuinely cares about my well being, I have been, for the most part, pain free. Unless somebody can provide evidence to me of a better solution, I will always be very open to this and other CAM - and honestly, I think that it is best to remain open minded to all treatment possibilities... I generally take the stance that "we don't know"... We don't really know much of anything... if we did, the research would not change by the day - drugs would not be recalled or given "black box warnings" post distribution.

I became an NP because I recieved horrible, useless and expensive care from not one, but FIVE different dermatologists who had no interest in understanding the cause of a very bad facial rash that I had for two years.... only drugs... to the point that I ended up with chemical burns on my face from the "bulls eye method" that one decided to use. Since no review of systems was actually completed, and since I was not a nurse, but a student, I did not know the standard of care that should have been used, there was no way that any of them would ever have identified that I had a severe mold allergy that was affecting not only my skin, but my digestion, mood, vision, and over all quality of life. However, I will still not say that all dermatologists are "quacks". I only knew that I could do a better job of caring for patients by actually caring about them and asking them questions and THINKING. It was actually a chiropractor who identified the problem. I had black mold in the apartment I was living in and the prescription was to move. This eliminated ALL symptoms. No body tested my blood, checked for lupus, etc.... things that I would do at this point before diagnosing me with an "anxiety disorder", which was what the last one did, and tried to give me xanax.

Even a lay person can see that this is genuinely F'd up! But not one medical provider ever addressed it as the issue - and I have to wonder how my life would have been different if I had not suffered YEARS of back pain - before FINALLY receiving excellent chiropractic care that has eliminated my pain... without drugs.

:)

[kodc]

I wouldn't work with one, see one as a "pt" or share a cup of coffee with one. Charlatans, every one. There is an abundance if EB data that demonstrates they are harmless at best and probably dangerous. Respect? I do not know a single medical professional who respects chiropractic "medicine."

i can't believe they are licensed, frankly. It's a massive fraud.

It's very unfortunate that whatever experience with a chiropractor you may, or may not, have had has gotten you so upset. I understand where this might be a problem. When I was a teen I had two very horrible experiences with two different dentists. Up to this day I have super high anxiety when I go for an appointment or even taking my children for a check-up. But, perhaps you haven't had a negative experience and have based your decision on who knows what.

I am currently a practicing chiropractor. I became one after being sent for relief by my physician while I was employed at the Great Mayo Clinic. Strangely enough, he was also employed there. Fortunately for me this physician was looking at me as a patient, someone who he cared for and wanted to see obtain the best outcome. His words, not mine - "go to a chiropractor. None of these drugs are actually fixing your problem. They are only masking the pain." He must be real nut-job, eh?

In my practice I currently work with chronic neurological conditions. My focus is there because I gravitated to it after seeing many things that made me want to learn more and figure out. So, that's where my post-graduate and fellowship training is. I enjoy helping others where they haven't been able to find help otherwise. However, my biggest wins are those that I may not have the best answer for are able to get positive results within a great referral network I use. I have several other providers in the area who are interested in co-managing, even taking over a case when it's in the best interest of the patient. Heck, these providers (NP's included) even refer patients to my office.

In case you're still following along with me I'll continue. For the past four years I have also been practicing inside an OB office that is located in one of the biggest hospitals in our area. The funny thing is that there are two physicians, one PA, two NMW/FNP's, and a half dozen nurses. The awesome things about that is we all work together to achieve the best outcome for the patient (including the baby on board).

I guess it took this post for me to realize that there are folks in all areas that I may not be the happiest to deal with - frankly, I was surprised at this myopic vitriol from someone in this field. But that's what makes the world go round. I've said for many years that NP's are my FAVORITE providers because they're willing to take a step back, survey all of what's around them, and give it a good go. I guess no one can bat 1.000, not even me with my DC license.

To those others that have posted negative experiences, if it's not right (or doesn't feel right) don't do it. I'm sorry for those that are taking advantage of either your credentials or the patient's trust. The Pollyanna in me wants to think that we all are seeking the betterment of humankind and that's what makes us tick. I hope that in your position you are able to move along and find providers that resonate better with your ethics instead of being on the lookout for the next big paycheck.

[crazynurselady]

Hi. I am new to this forum. I found your post by accident and joined because of it. I am experiencing the same problem. I passed cert and got my license. I applied at many places but they all wanted someone with experience. So I took the first job that was offered tome after getting turned down. Plus the area I live in is a small community, so not that many NP jobs available.

So, I went to work for a chiropractor and I am going through the same issues. I have been co-signing his notes since I started there in July. And now he expects me to sign all his chiropractic notes under just my name. I have not signed any of them because I don't see his name on them anywhere. I'm not sure this is legal and I'm very concerned about the possibility of Medicare fraud. I am not a chiropractor, so why is he trying to get me to sign his notes as if I have performed the treatments? This does not make sense to me. Do you or anyone else know if this is normal? Or legal? I know it's been a while since you made this post so I hope you or someone can give me some advice. I'm worried. I have already started looking for another job. Short of calling Medicare and asking them directly, I don't know what I should do. I wish I could just quit but I need the income until I can find something else. But if this is shady, then I am going to quit anyway. Plus, NO benefits...NONE.

[Psychcns]

@crazynurselady-- read your nurse practice act. It likely states what you can do. I think that in order to sign a note you have to assess diagnose and treat the patient. Do you have a job description, a collaborating physician. If your chiro is treating the patient he should bill under his own name..to me it doesn't sound good.

Have you looked into urgent care or minute clinics for work?

[lhflanurseNP, APRN]

I have to agree with Psychcns. You can work in the same facility as a D.C., but his patients and notes are his...and your patients and notes are yours. May you both see the same patients? Sure, why not. It would be no different that if you were in another space. The problem comes when the lines a blurred and it seems this D.C. is trying to blur the edges. If you see the patient, you should be signing in under your own account so that the billing is separate. I would definitely NOT sign ANYTHING that I was not involved in. Maybe your D.C. is not aware that this is illegal. Now, if he wants to put you as the "owner" and he works as an employee, then you would do the notes while he does the therapy...kind of like having your MA do an ear lavage, give an injection, obtain an EKG. Then it is under you license legally. If this is not the case, then run as quickly as you can and do NOT sign ANYTHING that you have not done yourself.

[crazynurselady]

Thank you for your response Psychcns. The collaborating physician is rarely in the office. He is basically a buddy of the chiro and he is the MD that is "overseeing" me. I was provided a collaboration agreement but it is basically just canned, nothing very specific. But it is with the MD not the chiro. I have looked at urgent care clinics as far as 50 miles from me. I have recently looked again and applied to many of them, even though, once again, they want someone with at least a year of practice. Fingers crossed. The chiro is treating the patient (or his MA/CA - when they have one and they stay). Another issue. He treats them on the opposite side of the office on a cox table ad in the PT area where they do some exercises and apply heat and cold packs, and they stand on a machine that shakes them for like 15 minutes. Sorry, forgot what it's called. And, frankly, don't care. Ha! He came and told me this arrangement with the notes was going to begin on October 1st along with the transition to ICD10. Which I do the coding for the diagnoses as well. I am not a coder. He told me he would input his portion on the note that would be assigned to my name and then I would need to put in a short note as if I had assessed the patient and then sign it. He said that I should maybe just pop my head in the treatment room and peek at each patient. His name is nowhere on the note. It will look as if I am doing the chiro therapy. Does this sound normal to you? I just don't know. I got a bad feeling in my gut. I am going into work tomorrow and I am going to talk to him about it and let him know that I am not comfortable doing this. I may not have a job after tomorrow. UUUGH. Thanks for listening. I will update and let you know how it goes.

[cayenne06, MSN, CNM]

I am currently a practicing chiropractor.

In my practice I currently work with chronic neurological conditions.

Do you subscribe to the subluxation theory of chiropractic? How do you treat these neurological conditions?

[Psychcns]

Does not sound right at all. Tell him you are not comfortable signing his notes as you have said. Why doesn't his buddy the physician sign them? If he needs a medical signature to bill and you are not examining the patient then it is fraud.

do you have a job description? What are your duties??

[crazynurselady]

Hi IhflanurseNP. Thanks for your input and responding. I am I'm pretty sure he's having his wife bill under my name for Medicare because it pays more. But I'm not sure exactly how she is billing it. I'm not signing any of those notes. I'm going in tomorrow and I'm going to let him know that I am not comfortable with this set up. If he fires me, I'm going to call Medicare and let them know that I am no longer working for them so they can't continue to bill under my name. Another thing, I talked with the NP that worked there previously and she told me that they tried to get her to change a date on a note so that the chiro's wife could get the insurance to pay the hospital bills for a minor accident his wife was in before I started there. She ended up with Bell's Palsy a month later and tried to say it was because of the accident. The previous NP obviously refused to do it. She has moved out of state but we keep in contact. She agrees that this new note tactic is shady. I'm going to ask him to show me something from Medicare billing that says this is how he should do it and that says it is legal. Never in my life did I imagine I would find myself in such a predicament. But here I am. I can't go in the office accusing someone of attempting to commit fraud, of course. I have to be calm and stay as professional as possible. I will let you all know how this turns out. I have already put out about 12 new aps. Either way I want out of there. I want to do primary care or urgent care. Wish me luck!

[crazynurselady]

My duties that are set forth in the employment agreement are just basic. It states "The ARNP may interview clients, obtain and record health histories, perform physical and developmental assessments, order appropriate diagnostic tests, diagnose health problems, prescribe and adjust medication, perform trigger point/joint injections, manage the health careof those clients for which she has been educated, provide health teaching and counseling, initiate referrals and maintain health records. Note the part that says "for which she has been educated", I have not been educated on chiropractic techniques. It goes on to list a bunch of diseases that any ARNP could treat and be comfortable doing so. It does list low back pain, fractures, bursitis, fibromyalgia, OA, OP, sprains, and strains. I see it also has rehabilitation listed. That's not something that we do in a primary care setting. Ridiculous. I have a sick feeling in my stomach when I think about it. I hope I get some phone calls soon.

[Psychcns]

Also consider your scope of practice as an fnp. I would be very careful thinking he can educate you on chiropractic techniques. You are an NP, not a chiropractor. also I think you are responsible for what is being billed under your name.

[crazynurselady]

I hear ya. I'm not interested in their techniques. I am only interested in doing what I went to school for. His wife does the billing in the office. She is not a certified coder or even an MA. They don't let me know anything about the billing. I have even offered to help up front when my schedule was slow but I get a vibe like she doesn't really want me to. She doesn't mind me answering the phone when she can't get to it but she has never tried to show me how to check someone out of the office after their treatment, etc. And he has said to me a couple of times "you don't want to have to deal with billing." Or "you don't want to know or need to know about billing." Apparently, I do. I could just be paranoid, not sure. But when it comes to my license, I am. I would rather have my license free and clear and no job than to lose it and not even have hope of getting a good job. Maybe they don't know what they are doing. And he thinks he doing what he's supposed to. If that's the case, I want him to show me the proof from a legitimate source such as the CMS.