A word of caution, MrScottyMD

[DSMMD]

I know that you are indicating that you are planning on starting your residency on the 2th. First off, congrats. However, I do not know how long you have off between finishing clinicals and starting the residency. Ensure that you have adequate time off as it takes time for the ECFMG certificate to get handled and for you to get your educational license in the state in which you want to practice. You should probably give your self a month at least.

The other word of caution is to be careful when you start your practice as an FP and also use your manipulation skills. You will probably need to have liability insurance for both your DC aspect as well as your MD scope. Because, if you are an MD using your manipulation techniques, you will probably not be covered as you will be practicing outside of the scope of your practice.

Just some words of wisdom(?)

[azskeptic]

You raise a good question, DSMMD...manipulation....is it part of the scope of practice of a physician?

In Arizona,where Scott is moving, you have the medical board

http://www.bomex.org/

Reviewing their rules and regulations you'll find no mention of manipulation.

Somehow though I think Scott faces some problems if he does an unproven practice (chiropractic manipulation) in Mayos. They are pretty straight in their medical practices.

[MrScottyMD]

I will absolutely not use any manipulation in my residency for that reason as I will not practice anything that can be construed as chiropractic while doing a medical residency. However Manipulation as a CPT code is a universal code that was changed from a chiropractic A2000 Manipulation code to a Universal 98241-98245 code (Manipulation by Physician )approximately 8 years ago. A physician who can use this code is either a DC, DO or MD and in some states PT. It is absolutely in the scope of practice of an MD to manipulate as long as he or she takes training in manipulation. Of course there is not an exact number of specified hours that is required so being competent in manipulation is really a matter if the MD feels competent to perform it or not. Manipulation for the treatment of subluxation of the spine is chiropractic but manipulation to improve range of motion and facilitate healing is within the scope of medicine and certainly is not limited to the spine. Its really a play on words and the techniques in fact are quite similar. Fortunately in AZ I will hold both licenses and carry malpractice on both degrees as chiropractic liability insurance is literally peanuts compared to medical liability. I will cover my bases, I have had the oppurtunity to own and operate 3 rehab clinics over 12 years and employed chiropractors and one DO and am very careful about the scope of practice and what a physician or medical tech, LPN, or an RN can do. As far as litigation goes you are always sued to your highest degree anyhow so in fact my MD liability would cover me but just in case I will always carry my DC liability.
Sincerely, Scott Jones

[etomidate]

DSM is right on the money. I am glad you are planning to hold both licenses, because for an MD even if you have been a DC this may be very problematic. Mainpulation may be theoretically in the "scope" of medicine, but it's certainly not an "accepted practice in the community". Should a malpractice issue arise, you will find that the other side will probably use an expert witness who will testify to this. I'd certainly check with your medical malpractice insurer and state board when you get into practice.

DO's are in another world entirely. Manipulation is an accepted part of osteopathic practice and DO's are urged to incorporate it during their school time. And you might be surprised that one of my DO friends who is an allopathic peds resident is getting some interest from his hospital for research into the effect of OMT on pulmonary function in critically ill neonates.

[MitchDC]

All you have to do is notify your medical professional liability insurance company and let them know that you plan to use manipulative therapy in your practice. They will likely raise your premium a few bucks and say OK.

For those of you who don't know, liability insurance for Chiros is less than $2000 per year. When compared to a generalist medical physician, that's barely a drop in the bucket.

IN most states, physicians (MD's) are allowed to do pretty much anything they want. If an expert witness testifies against you, you say that you also hold a doctorate degree and license in chiropractic medicine and the issue will be null (in fact, they would never call that witness and waste the $500 per hour knowing your expertise and education from prior case research).

In fact, if you want your receptionist to give injections OR even manipulate -- that's fine too! Clearly, you are responsible for that person, but medicine has taken a HUGE scope and freedom as compared to other health care professions.

Now, in regards to Scotty planning to hold chiropractoc liability insurance - that could also be a good idea. Your chiro insurance company (NCMIC, etc) will have the nations experts in chiropractic and manipulative medicine at their disposal).

This really isn't a big deal as long as you are honet and forthright in your dealings and take good notes on what you do.

I'm sure Scotty has himself covered.

MitchDC

[etomidate]

Mitch, I'm both an DC , an MD, and a former state board exam commissioner. I have been doing a little research into this. I first heard of this problem several years ago when I read an interview with an MD who had also been a DC who said he no longer did any manipulation and he gave the exact reasons I previously did. It is not considered a usual practice in the medical community, and your previous DC training may be a moot point if you go to court.

Here's an interesting thing. I was in the OR today and one of general surgeons asked me what I did before medical school. I told him I was a DC, and he was quite impressed. He asked me if I planned to utilize any of my chiropractic training when I finnish residency and I brought up the issue of me manipulating as an MD without a DC license. This guy is a very renown general, vascular and transplant surgeon and frequently does expert witness work. He agreed that it very well may be a problem.

I think you seriously underestimate how rabid malpractice attornies can be, and how much touble they will go through to get a settlement. Remember that we are in a crisis with 70-80% of the suits being frivolous, and many insurance companies will settle for small amounts rather than risk huge awards. A malpractice judgement against you, even for as little as a few thousand dollars can be a serious problem, not the least of which is an appearance in front of the medical board. I'd fully research this with a knowledgeable attorney before I started doing any manipulation.

[MrScottyMD]

I made an official inquiry to the Arizona Board of Medical Examiners regarding if manipulation is within the scope of practice of an allopathic physician. Manipulation is in the scope of practice of allopathic medicine as long as the physician can provide evidence that in fact he or she has received training in manipulation. The Board however only acts on complaint in this matter of manipulation. In other words if a medical physician causes harm doing a manipulative procedure and a complaint is filed with the board of medical examiners of AZ then they will determine if the physician in question has had training in this area assuming that the physician acted negligently or manipulated improperly. If the physician can provide no evidence of CME training in manipulation or manipulation training in medical school then he or she is subject to penalty. I have the feeling this is the case in most states as it is in AZ but any chiropractor turning MD must contact the state board directly to find out if there is any specifications with regards to the number of hours of manipulation training that an MD must have in order to perform manipulation. It is better to be safe than sorry. I will certainly take an Osteopathic Manipulation Seminar at some point just to cover my bases so I can at least say that I had chiropractic as well as medical training in manipulation although we all know the techniques in most cases are indistinguishable.

Best of Luck To All . Sincerely, Scott C Jones DC MS IV