by Peter Hamlyn
I have the good fortune to work in a genuinely multidisciplinary environment. Not just a polyclinic with a variety of different medical doctors, but one populated with chiropractors, osteopaths, acupuncturists, physiotherapists, podiatrists, massage therapists and fitness instructors as well as rheumatologists, pain specialists, psychiatrists, orthopaedic surgeons, neurologists and sports physicians. Some I had encountered in my former role as a consultant leading a major London teaching hospital’s neurosurgery service. However this wider experience has materially improved my clinical skills. Put simply, we all have a role to play and by working in the routine company chiropractors enhances the service I can offer to patients.
Of course I have long since encountered patients who have told me of their experience with these various treatments before. However, almost by definition they were those for whom it had failed and it was not until my work led me into a closely integrated healthcare provision that their role and expertise truly manifests.
At an earlier stage in my career I had had a similar experience with medical pain specialists, rheumatology, psychiatry and physiotherapy, when I had established a multidisciplinary spinal clinic involving these groups. If you do not ever work together you do not really know what each of you can and, just as importantly, cannot do. If you can drive and sail but have not yet started working with someone who can fly, your trips to New York are more laborious than they might be. It takes a few years of integrated management to get the full feel of another specialty.
It is right that chiropractic treatment is to be integrated into Great Britain’s NHS. It is also normal. In Denmark’s state run health service it forms the first specialist line for musculoskeletal patients. In the UK, a chiropractor’s basic science and clinical training in musculoskeletal disorders is very rigorous. It has been my experience that in comparison to medical students a chiropractic student’s grasp of musculoskeletal diagnostic and management issues is much firmer. Why would it not be when their years are devoted to this one area?
Clearly, orthopaedic surgeons, neurosurgeons, rheumatologists, pain specialists and the newly recognised sports physicians can assess back and leg pain. Equally clearly, it is seldom appropriate for these medics to form the principle front line of such a service. This is more appropriately the province of physiotherapy, chiropractic and osteopathy. Equally clearly, any system must not impair experienced general practitioners from directly accessing medical help when they are dealing with evolving neurological, scoliotic or inflammatory problems.
What then as a specialist spinal neurosurgeon do I tend to send on to the chiropractic? Pre and post operative cases for rehabilitation management, thoracic back pain and a potential army of folk who are in the middle phase between rehabilitation and acute pain management.
There is nothing too difficult in providing integrated healthcare in this way though the units need to be small and the goals clear. It is not the aim that patients see all of the specialists but ideally only those they need when they need them. This is achieved by allowing patients access the group via whichever specialist they have faith in, often at the direction of their GP. This may involve a patient with an evolving cauda equina syndrome seeing a chiropractor on the basis that they “know back surgery is dangerous”. Everyone, however frightened, feels the door is open. If the chiropractor then tells they had best go straight to surgery and “there is this nice man in the next room who I will introduce you to” they will do so reassured. It is safe if the neurosurgeon is indeed in the next door room and the group has a modus operandum of integrated care.
And of course, patients do not come with “cauda equine” or “chronic back pain” written on their pyjamas but with back pain and leg pain in the context of their social, psychological and cultural issues. You need to have open arms and many of them, if you are to effectively deal with all comers. So, it is a big welcome to our chiropractic colleagues. As well as the key to the NHS door I hope you soon get a prescription pad too!
Peter J Hamlyn MB BS, BSc, MD, FRCS, FISM
Consultant Neurological Spinal Surgeon
University College Hospital London