Background
Methods
Design
Setting
Participants
Analysis
Results
Acupuncture and chiropractic referral
Communication among PCPs, acupuncturists, and chiropractors
PCPs | A/C providers | |
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No effective communication | “We do not get any written documentation of what they’ve done.” | “There’s no effective communication here.” |
“I don’t know if I’m supposed to [communicate with PCPs]. I don’t know if they’re open to it, if they want to hear back how these patients are doing.” | ||
Spotty communication | “I’ve had a few [chiropractors] who have actually have sent me like their note or this improved. And that’s great. That’s wonderful. And I actually wish there was a little bit more of that” | “It’s rare, very rare [to interact with HMO clinician]. Usually, I’m communicating through the client. A couple of times through e-mail” |
Contrasting attitudes toward communication | “I think if I were getting reports from acupuncturists, I think that would just annoy me. So I’m kind of glad there’s not a lot of back and forth. I feel like, like getting a report from the dentist, I kind of don’t care.” | “I want to be working in conjunction with a primary care doctor.” |
“Frankly, I don’t have time to call any other providers or anything like that, unless they contact me with a problem. You know, I have way too many things to do…” | “I think it would be wonderful to have an open channel of communication with whatever the doctor is seeing, you know.” | |
“I mean, I’m certainly open to it, if someone has something they feel it’s important for me to know. But, the discipline is so very different from Western medicine, that I’m not certain how the information it would provide me would add to what would be familiar enough or make sense to me, to really add anything to what I’m already doing or what I already know.”“I think it [feedback from these providers] would be really helpful. I mean, I think that they probably have insight in terms of the pain…you know, the etiology, the non-physical etiology of the pain.” | “We do our chart notes. And I suppose, yeah, just sending chart notes back and forth. […] all doctors who have a full practice are very busy. And so are acupuncturists. […] would the doctor get the chart note or even want the time to review the chart note. I really don’t know in a perfect world how it could work. But I’m thinking e-mail with just something really quick, back and forth, might reassure the doctor too. I mean, I’m sure doctors worry. What the heck is going on? I haven’t seen this person. And they haven’t been back. And what are they doing? You know, that happens for us too. And we always like when people come back and say, oh, I didn’t keep coming because I got better, so… But there are people that you don’t really know where they stand, you know, how things finished with them or what ended up happening.”“He [PCP] doesn’t know if the patient got better, got worse, who they even went to. I want to use that place again because it seems like they have a pretty good success rate. Doesn’t happen.” |
Patients | PCPs | |
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PCP initiated communication | “I had gone to the doctor and he was amazed […] He asked me so many questions in regards to acupuncture and what [the acupuncturist had] done” | “I do follow-ups on the telephone within four to six weeks, or have them follow-up in the office” |
Patient initiated communication | “I just always think it’s very good, especially when you’re doing things that are considered complementary or outside their system […] We have to let [doctors] know what we’re doing, what works and what doesn’t work.” | “There’s the outgoing type of patient who’s open to anything. […] they’ll go ahead and describe their experience in great detail, for as long as I’m willing to listen.” |
Little communication | “And I don’t volunteer [information]. I mean, I guess I just don’t think of it.” | “It is probably the minority of people that report consistently.” |
“I can’t remember very much in the way of feedback [on acupuncture].” |
Patients | PCPs |
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“I guess it just didn’t really cross my mind to discuss it with [my PCP]. I guess he never said, well…Probably if he’d said well, [Name], you know, give me a call or come in and discuss it” “I never did [talk to my PCP about seeing an A/C]. […] I paid for it. They didn’t ask. They didn’t have any interest in any of that.” “[Interaction with PCP has changed] In that, when I go to see my primary care physician, I don’t tell her anything about if I’ve had chiropractic or massage therapy or acupuncture, or anything, because her attitude was not one that seemed like it was…would be received well.” “I just figure that I’ll talk about things that they [PCPs] will help with. And it’s only fifteen minutes. So, I will talk about the other things.” “Fifteen minutes is not enough time when you’re there for a sore throat or for something else. You can’t talk about everything. And I just figure, he really told me he didn’t believe in it. So I just go, forget it. You don’t need to know, I guess.” | “I get no records, and have no chart information, I don’t have anything to look at or review, it’s not like there’s something that’s going to trigger me asking it. Because, you know, if they go see the physical therapist there’s a note. And I can review the note. And I can see that their last three visits were with the therapist. And so I’m much more likely to say, oh, how did it go with the physical therapist? Whereas with the chiropractor, there’s nothing. It’s just a big blank.” “It’s like most of medicine, and what we hear about is failures. Okay? If they get better, nobody bothers calling us back. We only get called back if somebody says, oh, I didn’t get better. Well, if they’re better, they don’t come back and I don’t know.” “If they get the referral, I may not see them again for six months, or nine months, or whatever. And so, no, they don’t make that feedback loop to me that, yeah, it was great benefit. You know, was it the chiropractic, or was it the time that it had actually gotten better. Who knows. But, no, I don’t normally get short term feedback from patients who have gone to chiropractors.” |
“I’ve actually had less happiness with chiropractors the longer I’ve been in practice, just because of what I hear back from patients. […] part of it is I don’t know who I’m referring to. Because it’s this sort of contract, people that we contract with. […] I also don’t get notes back from them. So I have no feedback as to what they’re doing. Whereas, all the Kaiser physical therapists put a note in [the chart]… And I can review what they’ve done, and how many times the patient has gone and the progress they’ve made or not made.”
A/C providers | Patients | PCPs |
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“I tell the patient, you know, your headaches aren’t because of your musculoskeletal system is off or your mechanics is off. Your function is congested. It’s because your pain medication has side effects. So let’s talk about that. And then give them information that they can take back to their primary, and they can change their meds up.” | “Everything is on an electronic record and I’m supposed to get my medical record so I can give it a chiropractor, and then tell my doctor what the chiropractor…It’s like going out on this totally different area. When kind of the allure, at least for me with [HMO], is this kind of big, managed plan. But then I’m encouraged to go off on my own to go do something, without any…You know, it’s not like a chiropractor can look at my MRI. [Someone agreeing] I’m going to have to request my record, you know. And then is my [HMO] provider really going to trust what this chiropractor, who they don’t even know, is going to recommend for my care?” | “Usually what happens is the acupuncturist will tell the patient, this is a weird lump. Get back in to your doctor and have them check it out. And so then they’ll just come back in on their own and say, hey, they told me to come back and get this checked out. I rarely see any…There’s no back and forth otherwise.” |
“The patient should always go back to evaluate with their doctors, right? So I would think that the doctor would see the progress, from their patients, their firsthand report. Yeah?” | “And it annoys me when someone comes back with a wrong diagnosis having to do with their leg or their shoulder. It’s completely wrong. And yet they’re like, well, the chiropractor…You know, as if the chiropractor is qualified to diagnose that. […] it irritates me.” | |
“And, of course, I always tell the patient, especially if they get really good results […] I’ll say, you know, your doc needs to hear about this.” |
Patients | Pain clinic providers |
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“I had to be vigilant. And I had to stay on task. And I had to find help […] You know, I have a vested interest in taking care of myself.” | “So when you think about how to integrate the care and how to have it run smoothly, I think that works best if they’re a pretty motivated patient. They can communicate across systems.” |
“I’m taking a more active role. I didn’t know, really, what to expect or how to get the train to go the way I wanted it to go, so I kind of let them do the thinking and the planning. And this time, I made it clear from the very first visit that I wanted to look at maintenance.” | “So, for the patient who wants to integrate both into one, I think it then falls on the patient to be carrying […] the information from the acupuncturist to their primary care provider. So it falls on the patient to become that coordinator. And I think, for the most part, patients struggle with that, especially if they’re already dealing with, you know, lots of different health conditions […] it essentially stays un-integrated, unless the patient actively makes that happen.” |