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Dynamic Chiropractic Canada – January 1, 2009, Vol. 02, Issue 01
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The Road Less Travelled

The Pathway to Becoming a Risk Manager

By Greg N. Dunn, DC

I practiced in a small town on the prairies of central Canada for 23 years. On reflection, my office was more like a casualty ward in a busy hospital than a chiropractic clinic. I started practice at the tender age of 22. In retrospect, it seems way too young to be in charge of active patient care. When I started practice, the nearest colleague I had was 16 miles away and none of the local medical doctors would take my telephone calls. I was, in a sense, on an island and cut off from intra- or interdisciplinary care. I had to make decisions on my own and on the spot.

Over time this changed, and wonderful interdisciplinary relationships developed with the medical doctors in my community. Eventually, I was also able to have associates join the practice, as well as have other colleagues practice within the community, which fostered  intradisciplinary collaboration. Those first years were interesting, to say the least.

Farmers are an independent lot and often resist formal medical intervention. Once I became a part of the community and trusted by them, these folks came to me first. They came to me with fractures, chest pain, and abdominal pain. They came to me with musculoskeletal pain, too, of course. But often with very severe musculoskeletal pain. I had to learn to think fast and know when to refer. I had to know how to deal with in-office emergencies and know when I could manage the problem myself. I sometimes resented those early years, but now I relish the breadth of experience that I was exposed to. That was the beginning of my education as a risk manager.

In about 1978, I became a member of the board of a chiropractic regulatory body. I went on to become its president. I learned about the complexity of regulatory matters. I also helped draft a chiropractic act and took it through law amendments in the legislature, defending it at the third reading, just before its ultimate passage into law. It was during this time that my eyes were opened to the incredible number of ways practitioners could get into trouble. This experience has played a vital role in my ability to advise and assist practitioners who are confronted with any number of troublesome licensing board disputes and complaints.

The next stage in my education came through a series of interesting happenstances that led me to the CCPA (Canadian Chiropractic Protective Association). I began that part of my career in 1989 as a board member. CCPA deals with the nasty side of practice by assisting practitioners when they are being sued for professional liability (malpractice). Around 1992, I was tasked with developing risk-management programs for Canadian chiropractors. The risk management initiative came about as a result of our understanding that the best way to avoid the devastation of lawsuits was to prevent them in the first place. Doing these projects kicked my education up a notch. Our initial programs for risk management, in hindsight, were pretty simple and unsophisticated. That being said, two years after we started these voluntary projects, we began to see a dramatic downward trend in lawsuits against chiropractors in Canada.

The next and current phase of my risk-management education came when I began to work full time for CCPA in 1999. This allowed me to expand my horizons in two distinct ways. I began to manage the very lawsuits we were trying to prevent. This gave me unique insight into managing incidents. Lawsuits are probably self-explanatory to you; incidents may not be. Incidents are what happen in practice when things don't unfold as a practitioner expects. For the sake of argument, let's call these "unintended outcomes." This is where my past experience as a small-town rural practitioner and my experience developing risk-management programs for chiropractors joined with my emerging experience in dealing with the actual claims (lawsuits) against chiropractors. At CCPA, we encourage practitioners to call us when they have something unusual happen in their practices. We offer immediate guidance and support to the practitioner in order to help them manage the unintended outcome. Using this early intervention, we have enjoyed significant success in mitigating some troublesome practice problems.

With the foregoing in mind, consider this: When practitioners think about risk-management issues, it often evokes a negative response. When I speak or write about these issues, I have to overcome this natural reticence in my audience in order to reach them. In almost all instances, this initial negative response gives way to a feeling that "this is good, practical and very helpful stuff, and not scary at all." Let me explain. I've come to understand that practitioners do not want to be frightened by scary things that might go wrong in practice. They consider this to be negative and don't wish to expose themselves to these thoughts. Some wish to cling to the belief that every patient will be satisfied, and the notion that no patient will have an adverse outcome to their care. The flip side to this train of thought is: If you know where the potential problems are, you will be able to avoid them at least most of the time. If you are able to avoid the problems, it seems to me that your practice day will be much more enjoyable and stress free. Even so, suppose for a minute that even knowing where the potential problems in practice lie, you are not able to avoid them all? What if you have a patient who develops an adverse outcome during your care? Think of how empowering it would feel to know how to handle the situation professionally and decisively instead of appearing helpless to your patient. This is the essence of risk management. So, my view is that if you are educated and able to avoid or handle the problems you are likely to confront, you will be empowered and less likely to be frightened by the unpredictability of day-to-day practice.

In future articles, I will explore all sorts of areas where you can "risk-proof" your practice. I sometimes take serious situations and inject a bit of humour into the mix. The old adage "a spoonful of sugar helps the medicine go down" comes to mind. For today let me leave you with a "gem" that will be the foundation of many future articles.

When I review files of chiropractors who are in trouble, I look for some essential documented ingredients that will enable us to defend them vigorously. Is there a history? Is there an examination based on this history? Is the diagnosis in harmony with the history and examination? Did the chiropractor document talking to the patient about their findings, diagnosis, differential diagnosis and proposed treatment (including the risks, benefits and alternate treatment options)? Have they documented the treatment and progress in the SOAP notes? If these elements are in place, we can mount an awesome defence. Believe it or not, it really is as simple as that.

Dr. Greg N. Dunn graduated from Canadian Memorial Chiropractic College in 1976. A past president of the Manitoba Chiropractors' Association and the Canadian Chiropractic Association, he served on the board of the Canadian Chiropractic Protective Association from 1990 until his appointment as chief operating officer of CCPA in September 1999. Dr. Dunn is also a national and international lecturer on the topic of risk and risk management.

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