History is not an unarguable litany of events.
— John C. Willis
(Notes from the editor. Chiropractic History 1996 (June); 16(1): 2xx)
This story begins on a ranch in southern Oregon where Stephen Boone (not his real name) was a 35 year old ranch hand. One day he was out mending fences and, as he lifted a fence post, he felt a sharp pain on the left side of his groin. His doctor determined he had a hernia (1). He was scheduled for surgery, and soon the hernia was repaired. Because the injury occurred at work, Steve’s medical care was covered by his employer’s workers’ compensation insurance, and he collected disability for his time off work.
Steve recovered from the surgery and eventually returned to work. Unfortunately, this was not the end of the story but only the beginning of a horror tale that was to plague Steve’s life for the next two years. Soon after he returned to his regular work duties as a ranch hand, Steve noticed discomfort in the area of the surgical incision. This infrequent and mild annoyance increased in intensity and duration until he was in constant pain and could not work. The doctor who had performed the surgery determined that the pain was due to scarring at the incision site. A second surgery was planned to clean up the scar tissue, a procedure known as debridement.
Steve’s pain only worsened after the second surgery, and he developed radiating pain into his left testicle, which prevented him from returning to work in any capacity. His employer, through the workers’ compensation insurer, was required to pay him disability. The costs of this injury claim—the medical care including two surgeries and time-loss payments—were increasing each day. Insurance companies continuously update their data on the costs of various types of injuries. Expenditure’s for Steve’s injury were already higher than anticipated, but the ultimate price tag would be even greater.
Stephen Boone had joined the ranks of the walking wounded, people with undiagnosed, perhaps undiagnosable, injuries. He spent one painful day after another traveling to and from doctors’ offices throughout western Oregon. From Medford to Portland, he was referred from one specialist to another. He was examined by internists, urologists, neurologists, and, eventually, pain management specialists.
Steve’s quest for relief led him to Pill Hill, a dysphemism for the always growing number of clinics, hospitals, research labs, schools, and related facilities officially known as the Oregon Health and Sciences University (OHSU). The complex maze of buildings, sky bridges, roadways, and, more recently, a tram connecting the lofty campus with its newer riverside campus of clinics and wellness center, is situated high above the Willamette River near downtown Portland, but it can easily be identified from eastside locations as far away as Gresham.
In 1988, when Steve was seen by an anesthesiologist in the pain management clinic, OHSU had not grown to its current gargantuan size. The tram, and the controversy surrounding its erection and $50 million cost overrun, was still years away. Yet to sprout were the new VA hospital and the Doernbecher Children’s Hospital. Nonetheless, OHSU was at that time the largest west coast medical research and teaching facility between Seattle and San Francisco. Getting a referral to an OHSU specialist usually meant that yours was a tough case. Typically, patients hospitalized at OHSU were either indigents, complex pediatric cases, or medical emergencies. If Steve had invoked The Patient’s Prayer, his referral to OHSU was God’s way of saying He wouldn’t be swayed by it.
Steve’s condition did not improve as a result of the care he received at OHSU. As the name implies, the mission of a pain management clinic is not to cure the cause of a patient’s pain. By the time someone arrives for pain management services, doctors have essentially given up on determining a definitive diagnosis and curing the cause of the pain. Instead, they are hoping that the patient will learn physical and mental coping strategies to live more successfully with it. Sometime more aggressive and invasive procedures are employed to mitigate pain. Steve underwent a series of nerve block injections to decrease or eliminate his groin pain. This procedure is somewhat similar to a local anesthetic administered by a dentist except that the target of the numbing injection is a nerve root near the spinal cord in the low back. Furthermore, the numbing effect is intended to last much longer than a local anesthetic, hopefully permanently.
When the nerve blocks failed, a cryoprobe was performed to freeze the tissue, but the pain continued. Then a more radical procedure was performed. A surgeon sectioned the nerve root (a procedure that severs the nerve) to prevent Steve’s central nervous system from perceiving the pain. There was still no relief.
Finally, in what appeared to be an act of desperation on Steve’s part as well as his doctors’, he consented to an orchectomy, a surgical removal of the testicle. But the excruciating pain emanating from his groin continued unabated. Like an amputee who continues to feel pain in the severed limb, Steve experienced phantom testicle pain.
His low back pain started nearly two years after the hernia injury. An MRI showed left-sided neural foraminal stenosis (narrowing of the space where the nerve root exits the spinal canal, often due to arthritis). He sought care from a chiropractor who thought that Steve had injured his low back when he got the hernia, despite having had no back pain for nearly two years. The chiropractor contended the back injury was referring pain to his groin (2). An injury claim for the low back was filed, and Steve began receiving chiropractic treatments, which was also paid for by the workers' compensation insurer.
The insurer asked the Director of Pain Management Services at OHSU for his opinion. He thought the foraminal stenosis could contribute to Steve's low back pain, but he doubted it was causing groin pain. The doctor concluded that Mr. Boone “would best be served by a multidisciplinary pain clinic setting in which the patient is treated in a context of group therapy, psychological reinforcing therapy, and vocational rehabilitation.” He suggested obtaining an opinion from the medical center at the University of Washington in Seattle.
That is when the insurance company asked me for an independent opinion. They wanted to know if the low back diagnosis and the claimant’s need for chiropractic treatment was a result of the original injury. They had to decide if they should accept a claim for a back injury in addition to the hernia, which had already incurred far more costs than a typical hernia claim. If there had been a back injury too, then still more money would have to be set aside to administer the claim. Would the back injury result in additional loss of work? Would there be permanent impairment over and above impairment resulting from the hernia and all the subsequent medical and surgical interventions? If so, funds would have to be set aside for these eventualities. This is typical thinking for an insurance company employees. The concern is not just how much money is being spent on a claim, but how much has to be set aside for future related costs. If too much of an insurer’s assets are put in reserve, the insurer loses its ability to write new policies—a tipping point carriers don't want to approach.
As I read through the file, I saw that the handwritten chiropractic records were missing some important information. The site of the lower back pain was not clear, there were no examination findings, and it was unclear which treatment procedures were administered. What was clear was that, over a period of about three weeks during which Steve had been treated eight times, there was dramatic improvement in the low back pain and the groin pain. I had received the file about a month after the most recent office visit was documented, so I called the claims examiner to find out what had happened since then. She told me that Steve had experienced further improvement and had returned to work.
There was no mention of a low back injury on the day of the hernia, and the first time low back pain was documented was some two years after that injury. But, if Mr. Boone's claims of improvement were true, it would appear that the chiropractic treatments, albeit poorly documented, had caused dramatic improvement in a condition that had been steadily deteriorating for two years. Therefore, it seemed that the chiropractic treatments were appropriate and effective. How could I explain that the chiropractic care was reasonable and necessary for treatment of the groin and phantom testicle pain without allowing that Steve had sustained a back injury?
At that time there was a section in the Oregon Administrative Rules stating that treatment for a work-related injury would be payable if it was reasonable and necessary to the process of recovery. Additionally, I was familiar with research studies showing that irritation to various musculoskeletal structures—by injecting saline solution, for instance—caused referred pain in other areas in a predictable pattern. The irritated areas and referral patterns had been mapped out, and it was shown that irritation of lower back structures sometimes referred pain to the groin. It was also known that visceral structures—organs—could refer pain to musculoskeletal areas. Gall bladder disease often causes pain in the shoulder; pancreatitis creates pain in the mid back. So I wrote in my report that, at least hypothetically, it is possible for a groin injury to refer pain into the low back, and this could cause a biomechanical dysfunction secondary to aberrant proprioceptive (i.e., sensory) input (3). Treatment to the back could therefore be justified as being reasonable and necessary to the process of recovery without having to accept the back as part of the injury itself. This Solomon-like solution seemed to foretell a relatively happy ending. The insurance company did not have to add a back injury to Steve’s claim. He had recovered and returned to work.
* * *
Time passed, and I had all but forgotten about the case. Four years later a newsletter came in the mail. It had been sent to the 800 or so chiropractors in Oregon (at that time) by a disgruntled DC who apparently held a grudge against chiropractors who did IMEs. The front page of the newsletter featured an article titled “Pain, Pain—Where Is The Pain? Challenging Worker’s Compensation Successfully … Identification of Questionable IMEs.” It was coauthored by the chiropractor who had treated Mr. Boone. (The names of the author and coauthor have been redacted in the copy on this page.) The article started with a quote attributed to the patient: “They want to remove my other testicle, is there anything you can do for me?” As I read the article, the case began to sound familiar, but because it concerned an IME (an independent medical evaluation, which by definition includes a physical examination), I at first thought the two authors were describing an IME that had taken place sometime after I submitted my record review report. As I read quotes from my report taken out of context followed by cynical and derogatory comments, I realized that what they were calling an IME was actually the medical record review I had performed. Reading the lies printed in the newsletter, I was appalled to see how the two chiropractors had distorted the facts of the case, turning it into one in which the treating DC had prevailed over the workers' compensation insurer and its “dubious and apparantly [sic] anti-Chiropractic, extremely biased; [sic] Independent Medical Examiner, in this case, one within our own profession.” The article concluded, “Because of the completeness of [the treating chiropractor's] records [really?] and procedures, Dr. [Chiropractor] was able to persuade [the insurance company] to ignore the specious IME, and in the process cast suspicion on the integrity of the practitioner who performed the IME.”
As I read through this file, which I have saved for nearly three decades, I wondered why I did not take any legal action against the two chiropractors. The treating doctor had served on the Oregon Board of Chiropractic Examiners (OBCE). I could have complained to the Board. Perhaps they would have taken some disciplinary action for the fabrications in the newsletter. The doctor who wrote the newsletter was a member of the Board’s Peer Review Committee at the time of the newsletter. The Board may have viewed his deceptions unkindly too. But I had been reluctant to file complaints because at that time the OBCE had been hassling chiropractors who did IMEs. Complaints were filed, and certain chiropractors were charged with infractions. Some spent thousands of dollars defending themselves. I know of one case where a colleague and good friend ultimately got the Board’s adverse judgment reversed at the appeals court level. His legal fees amounted to about $40,000. I had myself experienced an uncomfortable experience with the boards' Peer Review Committee when I filed a complaint about a chiropractor whose patient I examined. The Board requested me to attend a Peer Review Committee meeting to justify my complaint. I thought that traveling from Portland to Eugene where the meeting was to be held, a two hour drive each way, was onerous, but when I demurred I was given the choice of attending the meeting or facing disciplinary action. At the meeting the questioning was more of an interrogation in which the opinions of my own IME, not the actions of the treating doctor, were challenged.
The only action I took in response to the deceitful newsletter was to call the chiropractor who had treated Mr. Boone. We had been on friendly terms on the few occasions we had met. He had even attended a seminar I taught. On the phone, this doctor sheepishly admitted to me that some of the information in the newsletter had been exaggerated, but he stopped short of promising an apology and retraction.
* * *
IMEs and record reviews provoke the ire of many chiropractors. Doctors who do IMEs are portrayed by other chiropractors and trial lawyers as hired guns who prostitute themselves for what is believed to be a highly lucrative income. (It’s not. Chiropractors who are overutilizers make a lot more money.) Chiropractors believe that IME docs will say anything the insurance companies want to hear because we are paid to do so, and this is the only way we can guarantee that we will continue to receive these referrals. There is little truth to this. I know of only one chiropractor who lost his IME clients, not because he didn't kowtow to them, but because his opinions were so slanted toward the examinees and the treating chiropractors that his reasoning wasn't supported.
I once received a letter from what appeared to be an IME company in Los Angeles soliciting my services. This was not too unusual, but what struck me as weird was the requirement that doctors who signed on with the company agreed to provide opinions favorable to the company’s clients. I responded that my opinions were never based on the source of the referral or payment. I heard nothing more from this company, but some months later I read that an Oregon law firm active in litigating workers' compensation and auto accident claims on behalf of plaintiffs, a firm that actively solicited chiropractors to refer their patients, had sent out the letter to entrap IME doctors.
Many chiropractors consider it treasonous for one of their own to give an opinion contrary to the treating chiropractor. I have mentored chiropractors wanting to do IMEs who told me they could never state that any care already rendered by a chiropractor was unreasonable or unnecessary. To a chiropractor, the idea that a colleague could do so is anathema and can be explained only by the IME doctor’s avarice and alleged incompetence at adjusting. Chiropractors who act as independent consultants are vilified in chiropractic publications, stopping just short of liable. When teaching an IME seminar in Florida, chiropractors who performed IMEs in that state told me of threats they had received from chiropractors who were aggrieved by their reports. One told me that a chiropractor whose patient he had examined had threatened to burn down his house. IME doctors are also harassed by state examining boards whose members are at times some of the biggest insurance abusers.
In cahoots with the chiropractors are plaintiffs’ lawyers who earn money from cases referred to them by chiropractors. There is even a chiropractic attorneys association for these lawyers. The lawyers themselves refer clients to chiropractors who provide prolonged and frequent treatment and often end care with high permanent impairment ratings. The need for a lot of treatment and an opinion of a high degree of permanent disability spell high settlements and jury awards to these attorneys. It is almost ludicrous to see how fairly simple and mild injuries can be turned into huge claims by these lawyers and chiropractors.
Footnotes
1. Technically, an indirect inguinal hernia where the abdominal contents rupture through the abdominal wall and protrude into the scrotum. TMI? Sorry. back
2. Referred pain is pain that is felt in a region other than the injured or diseased area. Someone having a heart attack will commonly feel pain in the left arm. There are no nerves that run directly from the heart to the arm, but because of the proximity of nerve cells in the spinal cord coming from the heart and from the arm, the brain perceives the pain as coming from the arm. In my experience, referred pain from the lower lumbar region to the groin is unusual, but injuries in the sacroiliac region, just a little lower in the back, commonly cause referred pain into the inguinal (groin) area. back
3. Proprioception is the body’s sensation of position and movement. Stand with your weight on one leg and you will feel how your body responds to the change in proprioceptive input. back
