Chapter 12 - Professional Relations

Sound intraprofessional and interprofessional relations establish a basis upon which one provider is able to access the services of another for the benefit of one’s patient. Cooperation between chiropractors and other health professionals has increased substantially in recent years. In this era of the health care team, managed care and increased external accountability for the quality and cost of care, good interprofessional relations will become an increasingly important daily need in chiropractic practice.

Primary care practitioners, such as chiropractors, have a particular responsibility to patients for maintaining good professional relations. Chiropractors must be aware of and adopt appropriate techniques and policies to facilitate good interprofessional relations. Recommendations are made regarding case documentation, referral protocols and interprofessional communication and cooperation.

For definitions see the Glossary at the end of this publication.

Case Management

Collaborative Care

Concomitant Care

Referral

Specialist

Therapeutic Trial

Third Party Payor

A. Professional Responsibilities

B. Referrals

C. Exchange of Information and Records Between Providers

D. Form and Content of Exchanged Information

E. Interdisciplinary Care Institutions

F. Economic Considerations

G. General Recommendations

Cooperation between chiropractors and other health professionals has increased substantially in recent years (Cherkin 1992). Along with this cooperation comes the responsibility of maintaining professional standards in all aspects of these relationships. The development of good interprofessional relations is the responsibility of the individual practitioner and is dependent on communication skills, professional deportment and personal rapport (Anderson 1992, Sawyer et al. 1988).

The many diverse issues that affect interprofessional relations include conflict of terminology (Anderson 1992), standard of professional brevity in communication (Cassidy, et al. 1985), unequal access to health care resources (Jamison 1987)), lack of a universally accepted defined scope of chiropractic practice (Haldeman 1976), variation in the nature of available chiropractic services (Jamison 1987), practitioner loyalty to their professional heritage (Jamison 1987, Curtis and Bove 1992), perceived lack of basic scientific evidence and clinical trials supporting chiropractic practice, distrust of training standards, and the thought that manipulation is a "dangerous intervention" (Curtis and Bove 1992). One must be aware of these issues when collaborative care is indicated. Where barriers to collaboration exist it is incumbent on the referring health professional to establish lines of communication based on mutual respect to facilitate access to other health care resources necessary for the patient's welfare.

For various reasons the best form of communication with which to establish good professional relations is concise correspondence. Letters are not only the most effective to foster interprofessional cooperation, but also facilitate practice management skills and increase the number of patient referrals (Cassidy et al. 1985, Long and Atkins 1974). Referral procedures that use telephone communication have been shown to be acceptable only when followed by a referral letter (Crone 1987). It has also been suggested that the referral letter can be a most effective means to educate the consultant on the nature and scope of chiropractic diagnoses and treatment for the given case (Jacobs et al. 1990). The act of an interprofessional referral may also benefit the referring practitioner by a reciprocal increase in return referrals (Banks et al. 1988). This reciprocal benefit has been shown to occur regardless of the method of interprofessional communication that was utilized (Jamison 1987, Banks et al. 1988).

Wider access to interdisciplinary facilities, both public and private, represent a reason why chiropractors must now concentrate on establishing better interprofessional relationships. The integration of chiropractic into such organizational structures requires definition of the roles of chiropractic and other health disciplines, and effective establishment of these roles requires developed skills in interprofessional relations.

The need for good professional relations with not only other providers but also employers, insurance professionals and attorneys, is emphasized by those agencies that regulate and fund health care in Canada and elsewhere. As Vear points out "chiropractors who choose to treat insured patients must understand the concepts of reasonable and necessary" (Vear 1985). Simpson and Tilden tell us that "many third party interests intersect with the doctor-patient relationship, and established standards may be applied to these third party relationships" (Simpson, Tilden et al. 1992).

A. Professional responsibilities

12.1 Informing the patient:

Where referral to another health care provider is considered, patients are entitled to a clear explanation of why the other provider is to be consulted.

Rating: Necessary
Evidence: Class II, III
Consensus level: 1

12.2 Developing relationships:

Every effort should be made to develop professional relationships with other health care providers so as to facilitate referral and access to other health care services and/or facilities where appropriate in the best interests of the patient.

Rating: Recommended
Evidence: Class III
Consensus level: 1

12.3 Credentials and scope:

One should be familiar with the qualifications and scope of practice of any practitioner to whom one makes a referral.

Rating: Recommended
Evidence: Class II, III
Consensus level: 1

12.4 Terminology and procedures:

One should be familiar with the terminology and procedures utilized by health care practitioners to whom one refers.

Rating: Recommended
Evidence: Class II, III
Consensus level: 1

12.5 Communication:

Chiropractors should develop good communication skills, as they are important in facilitating the transfer of information between providers, developing good professional relations and preventing any misunderstandings regarding the care or referral of a patient.

Rating: Recommended
Evidence: Class III
Consensus level: 1

B. Referrals

12.6 Chiropractors must consult or refer if the needs of the patient so indicate.

Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1

12.7 Chiropractors should accept referrals from other qualified health care providers, whenever they have the ability to provide a clinical benefit to the patient.

Rating: Recommended
Evidence: Class III
Consensus level: 1

12.8 Short term referral:

Short term referral due to absence shall not be considered a formal referral. Upon return of the managing doctor the patient and any pertinent data shall be returned as soon as possible.

Rating: Recommended
Evidence: Class III
Consensus level: 1

12.9 Referral with concomitant care:

Referral does not preclude concomitant care that is therapeutically necessary.

Rating: Recommended
Evidence: Class II, III
Consensus level: 1

C. Exchange of information and records between providers

12.10 When referring a patient to a colleague or other professional the managing doctor should provide pertinent information, so as to prevent delays and the duplication of diagnostic procedures.

Rating: Recommended
Evidence: Class III
Consensus level: 1

12.11 When accepting a referral from a colleague or other professional, the managing doctor should make every effort to obtain all relevant information so as to prevent delays and the duplication of diagnostic procedures.

Rating: Recommended
Evidence: Class III
Consensus level: 1

12.12 Information on the referral should also be provided to the referring doctor in the following circumstances:

(a) when the referred patient completes their regimen of treatment or has their treatment program altered; and,

(b) upon discovery of any new health condition.

Rating: Recommended
Evidence: Class III
Consensus level: 1

D. Form and content of exchanged information

12.13 Initial referral communications between the referring and receiving practitioners should include a written communication.

Rating: Recommended
Evidence: Class III
Consensus level: 1

12.14 When requesting patient information one should generally supply a signed and dated release form.

Rating: Recommended
Evidence: Class II, III
Consensus level: 1

12.15 Written reports or letters should include all relevant information which may include: patient demographics, history, relevant examination findings, radiology report, diagnosis, prognosis, the expected frequency and duration of treatment, results and a signed consent.

Rating: Recommended
Evidence: Class I, II, III
Consensus level: 1

12.16 Questions about care decisions made or recommended by another provider should be addressed directly to that provider in a constructive manner. Relying on the patient to be an effective messenger of clinically important information is inappropriate.

Rating: Recommended
Evidence: Class III
Consensus level: 1

E. Interdisciplinary care institutions

12.17 Practitioners should seek access to other health care facilities and institutions as necessary to meet the needs of their patients. This may include authority to admit or co-admit the patient into the appropriate institution.

Rating: Discretionary
Evidence: Class III
Consensus level: 1

12.18 Efforts should be made to present the patient with a providers' consensus on a recommended treatment plan.

Rating: Recommended
Evidence: Class III
Consensus level: 1

12.19 Where care is being given by two or more providers at the same time, they should communicate with each other to coordinate the patient's treatment/care.

Rating: Recommended
Evidence: Class III
Consensus level: 1

12.20 The resolution of disagreements between members of different professions on the course of care for a given patient should be based on:

(a) the best professional judgment of the practitioners involved;

(b) the objective evaluation of appropriate clinical options and intervention alternatives; and,

(c) responsible family involvement where appropriate.

Informed consent on the part of the patient continues to be necessary.

Rating: Recommended
Evidence: Class III
Consensus level: 1

F. Economic considerations

12.21 No referral should be sought or made principally on the basis of economic considerations. No fees, rebate or commission should be paid to any referring provider for the referral.

Rating: Necessary
Evidence: Class III
Consensus level: 1

G. General Recommendations

(a) When accepting a referral it is only a matter of courtesy to keep the referring health professional informed of your findings, recommendations and prognosis. These may be contained in your initial letter or in subsequent update letters.

(b) It is advisable to refer to chiropractors with a recognized speciality designation if it is felt that they are able to provide specialized care, in cases where such care is deemed necessary by the treating chiropractor. These referrals should be made on the same professional basis as to any other specialty.

(c) Patients may move or may find it easier to seek care at another chiropractor's office. Patients have the right to their choice of treatment and/or provider. These patients should have a letter of introduction sent to the new chiropractor. Information should be provided regarding the case history and diagnostic findings so that unnecessary repeat testing need not be done. The letter should contain all the information that one would include in any referral letter.

(d) Confidentiality of records must be stressed. Staff should be made aware that imparting information requested by telephone risks a breach of confidentiality. If patients request that information be forwarded to another party (i.e. insurance companies, lawyers, etc.) a dated release of information form should be signed by the patient before information is released.

(g) It is expected that copies of all correspondence be kept with the patient file and become part of the patient records.

(h) Attention to proper grammar and spelling is essential as this signifies overall professional competence.

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