20 I Spring 2018 www.anjc.info TECHNIQUE Council The use of clinical practice guidelines (CPG) within the chiropractic profession has historically been a controversial topic. In 2017, the American Chiropractic Association (ACA) adopted CPGs for the treatment of low back pain from the American College of Physicians (ACP) and the Council on Chiropractic Guide- lines and Practice Parameters (CCGPP). This generated a firestorm of debate on the issue of practice guideline utilization. From what I observed, the biggest issue had to do with potential liability from following the guideline in practice. This led me to inquire about how much risk is there from following a CPG. The literature lists several potential harms for a doctor who commits and adheres to a CPG. These include the risk that the CPG is flawed and inaccurate, outdated, Inflexible to apply to an individual patient, conflicts with other guidelines leading to confusion over clarity, and may open the doctor to malpractice liability by setting up a standard of care to judge them by. To answer the question in the real world of practice, I contacted five malpractice carriers, the ACA, Ronald J. Farabaugh, D.C. (former chairman of the CCGPP), and ANJC legal counsel Jeff Randolph, Esq. I asked several questions summa- rized the responses below: Do the adoptions of guidelines by doctors, state or national societies increase the risk of malpractice, because it gives a standard of care that doctors can be judged against? Guidelines include those from the CCGPP, ACP imaging criteria for LBP, etc. ChiroSecure: “Guidelines, in and of themselves, do not increase or decrease risk of malpractice. Guidelines are NOT standards of care.” NCMIC: “NCMIC does not dictate how doctors practice. Doctors of chiropractic are expected to use their best clinical judgement and act in the best interests of their patients.“ ACA: The ACA reported that they have not received any reports of unfavorable judgment based on any guideline. They referred to NCMIC to answer the questions of liability. Dr. Ronald Farabaugh: “In my opinion, NO. The research the ACA and others have done have pretty conclusively suggested that there is no evidence that “red flag” guidelines increase the risk of injury, or the risk of malpractice.” Jeff Randolph: “In my experience as a medical malpractice defense attorney for 20 years, establishment of guidelines by a state or national organization can be argued to set the standard of care and, if not followed precisely by a doctor, can be used against them at trial. “Juries typically do not get that specific as to indicate it was a deviation from a specific guideline, but I believe deviation from guidelines plays a large part in many verdicts against chiropractors in New Jersey.” Many doctors take X-rays for defensive purposes. They have been told by attorneys defending chiropractors and other experts that not having X-rays of areas they adjust puts a doctor at risk. Is there any validity to this statement? ChiroSecure: “Provider defense is not a reason to take X-rays. As noted above, allegations of negligence will be made in the absence of X-rays. We rarely, if ever, see allegations based upon taking an X-ray and it being negative for a given finding or possibility.” NCMIC: “….we do not impose requirements upon the practice models chosen by our policyholders. We simply require policyholders to practice legally within their states’ scopes of practice. Our commitment is to provide the best protection and defense to our policyholders.” Dr. Ronald Farabaugh: “That has not been my real-life experience over a successful 35-year career and in providing expert testimony in over 100 malpractice cases. It is simply not true. You should NEVER order a diagnostic test purely as a defensive maneuver. Any diagnostic test should only be ordered if there is justification after consultation and examination. “ Jeff Randolph: “I have experienced plaintiffs’ chiropractic experts taking the position that a failure to take an Are Clinical Practice Guidelines Risky? By Dr. David Graber Council on Technique and Clinical Excellence Chairman New Jersey PIP-PAY Associates Affordable Personal Injury Protection Billing and Collection Solutions For Your Office 973-772-2200 www.njpippay.com chiromatrix.com 855.973.6306 WE LOVE ORGANIC (Organic Search Rankings, That Is) Do something good for your website’s health. Call ChiroMatrix now.