Interdisciplinary Spine Care at Swedish Hospital

Today I'm here with Dr. Adam Swick. He's a chiropractor at Velo Sport Rehab in Washington State. He graduated from the University of Bridgeport College of Chiropractic in Connecticut and combined his passion for rugby and sports chiropractic by going to Sydney, Australia and practicing chiropractic. Now he's back in the States utilizing the latest research to guide his clinical approach using gentle chiropractic adjustments, soft tissue, nutrition, and therapeutic exercise. Dr. Swick thanks so much for being here. Can you tell the audience why you went to Australia, how long you were there, and why did you come back?

Dr. Swick: I knew I wasn't looking to try to set roots in the United States right out the gate. My partner was finishing up her master's studies overseas and it seemed like a really great opportunity for both of us to spend a year travelling and learning more about ourselves and where we might set up eventually. Speaking with a few of the mentors they had over at university of Bridgeport; Australia became my top choice. The decision to sit for the boards in Australia happened while we were traveling a few months after graduation.

I ended up getting connected with a multidisciplinary group in the heart of Sydney and practiced there for six months, before the realities of being in Australia, away from friends and family really started to hit home. Even though it was brief the lessons that I learned on how to manage patients, what practice style I would like to be involved with, and working with other providers within the healthcare system; were all invaluable.

The associate position that I ended up taking was in Bellevue, Washington. It led into the opportunity of working with one of the hospital systems on standardizing their integrated care pattern for spine care. Specifically a low back pain algorithm for how to utilize chiropractors within a hospital system.

Noah: Can you tell us about the multidisciplinary practice environment within the hospital that you have been working in.?How you got that opportunity, what the opportunity looked like and maybe guide students who may want to go in that general direction on what skills they would want to cultivate now?

Dr. Swick: The organizations I was a part of is a private practice that is integrated within the referral system for the hospital in Bellevue Washington. I got connected by dumb luck. I'm able to get on the coattails of an individual who has established a really well-known practice for the past thirty years. I have made some really positive and meaningful connections with the medical providers in the area. When the project first began it started with 13 clinics in the surrounding area of the hospital and those clinics were largely selected based on who the podiatrists were referring to for conservative care.
 
Initially they had established relationships, and they appreciated the work that the chiropractors did. Eventually the group had the means and the bandwidth to establish a larger program in 2013. Individuals within the hospital system that are presenting with a spinal complaint, if they are triaged and deemed that they are not in a progressive neurological deficit or they don't have red flags urgent enough to warrant a direct surgical consult are either tiered into chiropractic, physical therapy or podiatry; depending on their symptomology. From there that patient is then connected either with the hospital or the private practices in the area for what the patient wants and then also what is most indicated based on how they've presented.

From there it's really straightforward evidence-based care. Individuals should be responding within a short trial of care. If they're not ,you either need to assess what you're utilizing as an intervention or an individual needs to be transitioned to another provider that can provide the services that they're looking for and that is most indicated for how they've presented. If you are doing well by the patient, if they're improving then you just continue to monitor their progress objectively and subjectively. When it's done in that fashion it's really straightforward. Patients are highly satisfied and the hospital groups are ecstatic because you're a problem solver for that kind of difficult presentation of undifferentiated axial back pain.
Recommendations for individuals who are looking to get involved in a similar setup or individuals that are trying to possibly arrange something themselves. First step is to meet as many individuals within the medical community as you can. One of the most natural and organic environments for that are Grand Rounds. For every teaching hospital that I've been near their Grand Rounds are open and so you can attend and meet other like-minded individuals in the area and long before you'll receive a referral or get networked with an individual they have to know you. They have to like you, they have to trust you, and then based on that, and your ability to help them with their patients that is the fertile ground that can create this interdisciplinary model of spine care.

It is easier and I would even argue only viable if you have a champion from within the hospital who's really pushing the program. So as an outsider knocking on the door it is very unlikely that you will be able to initiate a program of this scale for such a complex program in a hospital system unless you have somebody within that's really looking to expand and try a new way and a new means of improving their spine care.

For our group that was the director of musculoskeletal medicine at Swedish hospital and previously for Dr. Lehman who was one of the mentors I had at the University of Bridgeport he had a mutual patient or a connection within the hospital system that really was the facilitator to champion him as a provider to make it all possible.

Noah: I just wanted to clarify to make sure I'm understanding the system. The clinic that you work at is basically a referral source for the hospital so you you're not an employee of the hospital or you're not directly related to the hospital outside of being a place that they refer. Is that is that correct?

Dr. Swick: It's exactly correct, even the pilot program that was initiated four years ago has expanded to the greater Seattle area. My understanding is that there are about 70 chiropractors that are involved across 40 miles.

Noah: Does the pilot program have a name and is there was a way for enterprising individuals in other areas to use that as an example of this working and try and implement a similar program in their local communities?

Dr. Swick: The Swedish chiropractic pilot program for Swedish hospital is the name of the organization the pathway that has been standardized across Physical therapy, chiropractic, podiatry, surgery and then what's considered their restoration or functional restoration program. This is all proprietary for Swedish hospital so unfortunately that's not information that I can share at this point in time because it's property of the hospital itself. I can talk about the relevant research that has been helpful in opening doors and kind of getting a place at the table as far as spine care and what that means being a chiropractor who historically hasn't had a place at the table within the hospital system.

I’m happy to field any questions from any individual who would like to know more about the program that we're currently doing or how they can start to replicate some of the steps that were required four years ago to get the program off the ground.

Noah: You mentioned that you were volunteering in some capacity and I wasn't entirely clear on what capacity that was. Could you clarify?

Dr. Swick:  So a lot of what it took to get the program off the ground has been unpaid service. So the research that has gone into citing the different steps of the pathway, the indications for when referral should happen, and what a minimally clinically important difference looks like within spine care. All of those items and all the information that went into drafting that was uncompensated. It's expected that we will create more of a referral pathway and more patients coming into our office, but up until this point everybody involved with the pilot pathway has been uncompensated for their services.

Noah: I feel like the work that you're doing with Swedish hospital is somewhat groundbreaking of really figuring out where chiropractic is in the whole spectrum of different practitioners. Do you feel that you're doing something pioneering in terms of the work that you've been doing with Swedish hospital?

Dr. Swick: I cannot conclusively say that this is the only hospital system of this size utilizing a standardized pathway happening within the United States because I'm not aware of every hospital system across the United States, but it's the only one that I'm aware of. It is pioneering in the sense that we are attempting to do something by bringing in over 40 different clinics, with different systems, with different providers and saying this is what we agree are the expectations of being a part of this program. Not all practices want to follow the standardization and the rules. There is a lot of interesting research looking at who will respond specifically to manipulation, who will respond more towards a stabilization exercise program, individuals more likely to respond to a psychosocial intervention within the spine care pathway at Swedish hospital. If we can take that opportunity we are very well-suited to be able to delineate and stratify those patients to get them great results.

One of the really humbling aspects that I've experienced in practice and then also in conversation with other providers is that spine care isn't easy, it is confusing, there's a high level of uncertainty with pretty much every patient that you interact with on a daily basis and people experience that as well so they’re suffering and they have a million different thoughts, a million different anecdotes coming at them for what they should be doing. Be it ice, get heat, painkillers, anti-inflammatories, massage, chiropractic, and acupuncture. So being that expert within spine care to dictate who is going to be best served by what provider is a really challenging position, but if we can own that as a problem solver we can not only establish ourselves in a much higher level of cultural authority at large, but position ourselves as a highly necessary aspect of hospital systems across the United States.

One avenue for people to learn about you learn about the research that's available in terms of our place in the whole spectrum of healthcare is the suggested reading list for the World Federation of Chiropractic. It shows where we have the evidence to support what we're currently doing and then the emerging evidence for where we'd like to go. Since the Swedish hospital pilot program algorithm is proprietary to the hospital and I can't provide much information on that for individuals who would like to get in contact me I can be a facilitator or liaison for anybody who's looking to try to get a similar project off the ground. Chiropractors don't have to operate within their silo, we can be a very valuable member within a spine care team if we step up to the plate and we start utilizing the phenomenal education that we receive to its highest level.

See the entire interview here: https://www.youtube.com/watch?v=46fKgkwUtO0