Primary Spine Practitioners, CRISP and Better Back Pain Care

I'm saying this because I want to be honest and upfront with people. If you went to chiropractic school or you went to physical therapy school, you were not trained to be a primary spine practitioner. You were not given all the knowledge and skills to serve in this new innovative role. You were given many of the skills that are needed, but you weren't trained with everything that is needed or even close to anything that is needed to serve in this new innovative role. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery.

And now, your host, Dr. Sebastian Gonzales. Hey, everyone. It's Dr. Sebastian Gonzales, your host with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. This is your first time in the podcast. Welcome. You're going to be spending about 45 minutes to an hour with me, probably an hour today, listening to either me talk in isolation to a wall full of foam and sharing all the information that I know about a certain topic in regards to the healthcare field, or I'm going to be interviewing somebody. And as you see by the introduction today that I'm interviewing somebody, and this is Dr. Donald Murphy, nickname Murph, and he is the author of the CRISP books.

And if you have not already read the CRISP books, just go through on Google and type up CRISP. That is exactly how it sounds. CRISP Murphy books, and you'll find them. And they're actually, if you're, I don't want to say if you're even struggling to manage spines, but if you're looking to improve your game significantly, you go through those books, I'm telling you, if you haven't already been exposed to that type of stuff, it's actually life-changing. And so his thought process, his methodology of all of his clinical years of practice are laid out in that book, and it lays out a whole forum of things you can learn from there.

In his book, he actually has things like suggested reading and so on, and a lot of the readings that are suggested are things that I've already read, and so I'm resonating very well with the stuff that he wrote. He has one on cervical spine and lumbar spine. I personally have them both, and I would suggest to everybody, if you're working with somebody with spinal-based problems, you need to get and read the book. So let's get first on to the personal story. Again, this is your first time to the podcast. I typically share a little bit about myself via personal story, just so you can get to know your hosts is all.

And so I'll share that right now, and we'll get right into the episode. So if you've already been following me a little bit on Instagram, that's performancehb, I've been attempting to do more automotive work. And so I have this old 1934 Model A that I got when I was 15 or so, and so I'm 37 right now, and it hasn't moved. I mean, we started the engine one time, and actually it ran when we got it, and we're converting it into a hot rod. So we've got a 350 cubic inch new crate engine, 350 output horsepower, and we've upgraded the suspension, box of frame, painted it, all that type of jazz. And so there's a lot of stuff that I've been doing lately in an attempt to make it run, and I'm currently on electrical, if you've been following me.

So electrical as well as putting together the soundproofing, because that thing's going to be really loud when it actually starts to go. And so we're about six months, I think, away from getting it to really work. But I stalled on it for many years, and because I didn't really have the money for it, but I realized that it's sitting in my parents' garage that I thought it'd be a good opportunity to make a good excuse to go to my parents' house more. And so I see my mom when I'm over there, my dad works on it with me, and so I thought it'd be a good opportunity to do that. And so although I'm dumping some money into a car, I thought the net result would be hanging out.

And so that's something I'm excited to do recently. And so if you don't see the progress on that, that's at performancehb on Instagram. Here we get into the interview. All right, everyone. Welcome on Dr. Donald Murphy. Hey, how's it going? I'm doing great. How are you? Doing great. Would you like me to call you Dr. Murphy, Don, or Donald? Wow. I mean, my friends call me Murph, so Murph would be fine. All right. I'll have to remember that. All right. Can you let all the listeners know a little bit about yourself? It's a lot of health care, chiropractors, PTs, ATCs, and trainers. So let's relate it, I guess, all to that.

Okay. Sure. So I'm a chiropractic physician in Rhode Island, and I've been in practice for 30 years, most of that time in private practice, but the past 20-something years practicing as a primary spine practitioner within my community, and then it started in 2016, I came on board with a integrated hospital system to implement and serve as medical director of a high-value spine program. How did that come to be? Did they approach you with working in the hospital, or did you have to kind of hustle them for that kind of thing? Yep. Yeah. So what happened was the integrated spine pathway that I'm a part of developing and implementing in various locations was done by a team.

And we started doing that, developing that pathway at a small hospital in Massachusetts. And so the medical director of that hospital at the time ended up moving here to Rhode Island, and he's now CEO of a multi-hospital system. And so he and I talked, and he knew what the pathway was, obviously, because he was the leader, basically, of implementing that program that we had developed. So he saw the high value of it, and so he and I talked, and he brought me on that way. Nice. Yeah, because I was wondering if, in my personal experience, to talk to, sometimes to talk to establishments like that, or I guess our, I don't want to say primary care, like Realm, but our, since we're chiropractors, we're kind of alternative care.

And so I feel like that communication, a lot of times, is kind of rough, at least for me. And you successfully got that to happen, and it's just interesting that it didn't even happen at all. When you met this guy, anyways, how did you guys meet, and how did that all come to play, where he actually had you start working with people in his first hospital? Yeah. Well, how this all started was that one of my partners, his name is Dr. Ian Paskowski. He's in Plymouth, Massachusetts. And this medical director had contacted him and wanted to bring on a high-value spine program. And high-value spine program means providing patients who have back and neck problems up front with the kind of primary-level care that is most likely to get the best outcome with the necessary care that they really needed, which is, you know, in the spine world, this is the exact opposite of what we normally see.

What we normally see in the spine world, especially in, quote, spine centers, unquote, is that patients with back and neck problems get everything that they don't need and get very little of what they do need. And so that is what has what resulted in the present low-value environment that we have almost everywhere in spine care. So people are getting the most invasive and expensive procedures when what they need is minimalist procedures, and they need to be taught how to take care of themselves maximally. And so what the hospital system was interested in was high-value spine care. And so we developed this partner of mine, Ian Piskowski, brought us together and said, well, let's work together to develop a high-value spine program.

What does that really look like? Let's put it together. And so we did. And it ended up to be a really cool pathway. And so as a result, we've implemented this in other environments. And so, again, the visionary within that hospital ended up moving to here, to Rhode Island. And so that's how he and I came together to implement it here. Yeah, nice. Yeah, it's funny you say the spine specialist centers. And just what comes to mind is the stereotypes of when people have come into an office like yours or mine or, you know, and they're like, I tried everything. I went to this specialist and I went to, you know, I tried decompression and we tried this, we tried that.

And sometimes, not all the time, but sometimes, like, I personally am like, oh, dude, like, this camp, this probably is not that complicated, you know, and we just do some very simple things to get the air to desensitize and we'll be perfectly fine. And just in my observation, sometimes when they've gone through that, I guess I would deem that the ringer, they become very, they're very keen to what needs to be quote-unquote fixed. And it's, I feel like they've gone so far down the rabbit hole sometimes, it's hard to dig them out of that thing, you know? Right. That's exactly right. And that's the, that's a good point because that's the very thing that we're focused on is, you know, what happens with that patient up front when they first encounter the healthcare system?

What happens then at that initial point is what, to a large extent, determines how things go down the road, whether they rapidly move in the direction of resolution of the problem, which in most cases is, is very easily, easily accomplished, or whether they are likely to run down the, the path of, uh, just descending into chronic pain, which is almost never, uh, inevitable or necessary, but is all too common. Yeah. Um, yeah, if I, I was talking to an intern actually yesterday, I have one that we were talking about the, uh, the difference of treating somebody like, so we have a lot of, I would deem them as high function people here.

Like they're, they're, they're very motivated to move. They're not, they're not really afraid of what they have. They, they know they're going to get better and, and maybe they came in, luckily they came in like that to me. Um, but there's been a few that have been like more of the, the rabbit hole chronic pain. And, and I know that this might be my problem a little bit, but sometimes these people, I stay up at night, like thinking about them when I'm sleeping and how I could do a better job with them. Um, and so as she's going through her development of what she wants to do for a profession or what patient population to work with, she's like, well, I like people with chronic pain, but also like these high, high, um, like high function runners.

And I'm like, dude, those are, those are way different populations. And so I don't know if you can, um, just for her sake, cause I'll have her listen to this later. What's your, what, what's your experience of working with, with either one of those populations? Well, I, I've worked with both those populations and, uh, they're, they're different for different reasons. Um, and, uh, so, but they have common characteristics in many ways, but they do, they do require different skill sets. So, and, and, and, and mostly in not only what you do and your everyday activities with them, but also your communication with them, what they, what they need, uh, in terms of your, um, your interaction with them, um, how you need to communicate with them.

Usually the chronic pain patient needs to be motivated to become more active. Uh, the, uh, high functioning athlete needs to, uh, be motivated to, um, engage in activities. That is the right thing to do the right activities. Uh, we don't have to motivate them to be more active. That's for sure. But we do have to motivate them to be smart about activity. And so that's, those are different skill sets. I didn't, and I certainly think that anybody is certainly capable of developing both those, uh, divergent skill sets. But as long as it's, it's really important that we understand the difference, the different skill sets that are required for these different populations.

I know that you covered a little bit in your book and, uh, by the way, great job on the books. They, I read, uh, uh, uh, cervical and lower. You don't have another, right? Uh, I have, I have an older book on the cervical spine, but, uh, my, my two most recent ones are the, the, um, one on the, on the low back and one on the neck. Oh, nice. Yeah. I, I, I loved them. Like the, the thought of how you put the, the clinical flow together, the three questions to ask or to ask us internally, um, and then the application of, um, manual care, as well as the, your, your, your, uh, your MDT or end range loading, and then out into like more of a, um, um, like a corrective approach, I would say, I think it's great.

And, um, it's surprising to me how many people have not read it. And when you, I'm just curious that when you wrote the book and I do know a lot of people that have read it, that's why we're talking. Um, but, um, when you wrote the book, what, why did you write the book? Cause like, what problem were you trying to solve? I know I've written something for, like, I was trying to solve a problem and it was frustrating to me inside. I don't know what you were thinking with it. Yeah. Yes. And it was motivated by solving a problem. And what, what that arose from was my frustration in my training, um, as to, um, you know, not really gaining an understanding of how do I, um, get to know this patient and get to know what's really ailing them.

And how can I identify the factors that are contributing to whatever is ailing them? And what are the things that I can do that maximally helps them overcome the problem? I've never learned that in my training and that's not a knock on chiropractic schools or anything else. It's just, that's what training, where training was. And so I said, there's gotta be a better way to do this. So I went to the literature and I said, I'm going to, you know, the literature must have the answer. So I read the research, uh, literature, thousands and thousands and thousands of papers and books and, and found out there's a lot of information out there that helps us to diagnose patients and to developing a management strategy that's most likely to benefit them.

But the problem there was that the information was all over the place. It was all in disparate, um, fields and specialties and, uh, journals and it was all over. And I said, this needs to be brought together into a cohesive approach. Uh, and so that's what I did. I brought that, all that information together and to a cohesive approach. But then I thought, well, you know, if you can't do this in a busy clinical environment, then it's not really of much benefit, you know, helping three people a day. Cause you, you have to spend so much time on each one. Well, you know, that, that, that's not a viable way to conduct a practice.

So, uh, uh, we have to not only make it, uh, inclusive of all the information that is available to us to, um, to understand all of the things, the different things that can contribute to the patient's pain, disability, and suffering experience. But we also have to, uh, have an efficient way to apply this information so that we can maximize the efficiency of our, uh, our conduction of our, our everyday practice. And not, as I said, not spend, you know, three hours with every patient. But this was a evolution that took place over decades and it was a lot of work, but it was well worth it because I, I gained a level of confidence in my ability to really understand my patients, really understand what's contributing to their problem and, uh, be very confident in my ability to help them overcome the problem as, as quickly as possible.

Yeah, I think, I think you're right with the timing thing. And, uh, I know that with, even for me with implement, implementing, like, let's just say I just switched over, uh, EMRs and I did really didn't want to because I didn't want to fuss with it and I didn't want it to, to steal away time from the rest of my day. And so when people are attempting to implement the stuff that you're, that you're talking about, um, can they expect to, uh, how long does it take you with, with, I guess, one patient in this setting? Let's just say a new patient and then a followup. Yep. So everybody's different, but, um, typically the, the, uh, first visit with a new patient, um, we will usually, um, schedule an hour, but you know, some of that time is, is them, uh, doing their paperwork and, you know, their intake and, and outcome assessments and, uh, and other questionnaires to help us understand their, uh, psychological factors that may be contributing, et cetera.

And then, uh, I'll spend the remainder. So I, I may re I may spend 20 to 40 minutes with patients on the first visit. And then, uh, for followups, uh, patients will be scheduled, uh, 10 to 15 minutes. Oh, perfect. Um, so you have to be really efficient with what you're doing, but it's very, very possible. So what is, what does that first patient encounter look like? And then, uh, in case I've got to ask later, I want to see what the followup patient visits look like. Okay. So a patient comes in and, uh, they, they, they, uh, fill out their intake form and forms and their, uh, other other questionnaires that I use.

I can get into detail with those things if you want. And, uh, then I entered the room and, uh, and the, I, I put my mind in the most important thing that I can do in that moment, that initial moment. And that is make the connection with the patient, connect with them in a way that makes them feel comfortable, makes them feel valued and cared about, uh, and, uh, establishes a healing relationship that the healing relationship, um, uh, involves in my mind, how can I be most helpful to this individual and in their mind, gaining a comfort level with me. That's the first and foremost, before I start trying to gather information, which is of course very important, establishing that healing relationship is upfront.

Then going through a, a standard, but very efficient history that by which I gather the, the key elements that, that I need to know to arrive at a suspected diagnosis on history, and then undergo an exam that, again, is maximally efficient in helping me to find out all the things that I need to know about confirming the suspected diagnosis in this case. And then I, right on the first visit, I, I talk about, this is what the problem is. This is what I, this is what, these are my expectations. These are what I suggest we do. Then, um, I, I do remember in your book, you said something effective that we don't need to know a hundred percent sure what the inform, what the diagnosis is, but we need to be able to beyond reasonable doubt, just follow it or something of that nature.

Is that a, it, unless I'm reading another book. Well, what, what I'm saying is that we need to, uh, use evidence-based means of taking a history and exam to arrive at the diagnosis. Um, we don't necessarily have to be 100% sure of what the diagnosis is because you, you, you can't, I mean, most of the time you can, but not always, but we want to, to arrive at the, the working diagnosis and clearly explain that to the patient. You know, there's a large, there's a large literature out there on, uh, what patients are look for looking for in a, uh, in a, an encounter with a healthcare practitioner, people who have back or neck pain and consistently the, the number one, most important thing to patients who have back or neck pain is what is the diagnosis?

What's, what's going on with me? And they're not looking to know with 100% certainty. They just want to get an idea. You know, what's, what's going on with my back. And, you know, and the reason why I make such a big point to that, and probably with your audience, this is not a big deal. Uh, but in the greater healthcare system, it is, especially in spine is that people, uh, have kind of attached themselves to this idea of non-specific low back pain that, you know, it's where we can't be sure what's causing their pain. And so that, you know, 85% of patients, we have to label them non-specific low back pain.

And that is number one in 30 years of full-time spine care, uh, practice. I've never seen a single patient who had non-specific low back pain, but also if you tell a patient, you know, you have non-specific low back pain, what, what's causing it? We don't know. There's no way to tell you, but how can you, you're an expert in this field. How can you not tell me what is causing my spin, my, my problem? I'm sorry, but the literature doesn't allow me to tell you what the problem is. They're going to, sorry about my, no worries. Was that Cher? No, it was, um, um, Martha and this Vandell's, Vandell.

But if you, if we are not going to tell them a diagnosis, they will be more than happy to run down the, run down the block and find another practitioner who's more than happy to, to, to give them very specific information. And it may be all wrong and it may be part of a scheme to sell them on all this stuff that they don't need, but at least they told them something. So better than that. And the, and clearly the literature, uh, tell the information that we have from the literature tells us that yes, we can tell patients specific things about what's causing their pain. Evidence suggests that we can tell them they have either disc pain or joint pain or nerve root pain or muscle pain.

And we can, we can determine that and we can determine if they've got motor control issues, nociplastic pain and, and other things. And we can communicate that with patients in a way that status is satisfactory to them, empowers them and empowers us to be able to maximally help them. Yeah, I think, um, like one thing I've added to, to my interaction with patients and I've, I've, I've been trying to do a really good job of communicating with them and thinking about what they're going to wonder when they walk out the door of things. I should ask that. And so I keep thinking that they're going to go home and they're going to Google what I said.

And so I usually tell them, look, you have back pain. I'm going to be screening out nerve root, pinch nerve, I'll try to say general terms, pinch nerves, um, disc herniations, uh, facet irritation and puriformis syndrome, muscle spasm, and even way down, way down into the hip. So, cause I don't really don't want them to go through too much and start to muddy the water with generalized stuff that they've read on the internet, which is going to confuse them. I think in, in, in my opinion, um, I'm just hoping that they trust me enough to, to come back so I can help them. Um, just, and, and they, but by, through your ability to number one, do a, an examination that reproduces the patient's pain and you've gone a long way.

And then, and then a clear, um, understandable explanation of what you found, boy, that, that, that there's a very low likelihood of somebody, you know, um, running to somebody else to try to find a better answer. If you've come up with the answer. Yeah. Um, curious, cause they said, you said something earlier about, um, giving them, giving someone the wrong diagnosis in another place. Um, have you, how do you address the idea of degeneration that they come in? They say they have a degenerating spine. Oh, that's, that's one of my favorite pet peeves. Well, a big part of my training is, is training primary care doctors, um, to function, uh, to, to understand back pain, uh, better.

Cause most of the time they didn't learn a whole lot in school. And so, uh, I've been T I've been teaching, uh, internal medicine and family medicine residents for the, for 20 years, uh, doing classes on back and neck pain. And, uh, one of them, one of the most pervasive, um, factors that lead to what I refer to as iatrogenic imaging disability is degenerative disc disease or disc bulges. And so a lot of times, unfortunately, people have had patients will come in that when they've had imaging that they didn't need in the first place, but the imaging was ordered by somebody who didn't know any better and, and didn't know that they didn't need imaging.

And so they started hearing all this, these scary words, degenerative disc disease, disc bulging, uh, spondylosis, uh, that sounds like a serious illness and especially degenerative disc disease. I mean, a degenerative disease, imagine what that sounds like to a lay person. I have a degenerative disease. We should figure out who named that and, and just call them in and just interview only them about that. Why did you call this degeneration? Yeah. Well, we know, we know, you know what I call it? Gray hair of the spine. Yeah. Wrinkles. That's what it is. Well, it is. It's gray, gray hair of the spine.

It's a natural part of the aging process. It's not pathological. It's not a disease. It's not anything to worry about any more than gray hair is anything to worry about. Uh, we don't have clear all of the spine, but other than that, it's really not of any concern. And it is not certainly not a disease. So, um, uh, on the, on that same note then with, since you said when imaging is appropriate for all the listeners who are just getting into practice, when is it imaging actually appropriate? Um, the short, the short, the short answer is very, very, very uncommonly. Okay. The, the, the, uh, expanded answer is if somebody has clear historical or examination findings that suggest that they have a, an illness, a true illness, uh, cancer, infection, um, benign, um, tumor in the spine.

So, um, if you have a patient who has a, has a clear indication that they need, um, surgical consult, you want to order an MRI in that case. Um, so that the, you know, if you're going to send somebody to a surgeon, you want them to have the MRI when they see the surgeon rather than having to see the surgeon, then, you know, they can't tell us, tell them anything yet until they go out and order the MRI. So, if, if, if somebody needs an invasive procedure, like, like an injection or, or a surgery, or they have clear, um, historical and examination findings that suggest the possibility of a, a, a serious illness, then they need imaging.

Anybody else does not need imaging. Mm-hmm. When, um, just, just curious, I did have a gentleman that came in that, uh, recently that he was, um, he had back pain that was over 65. And so, I did an image screening on him just, just to chest out malignancies just in case. Um, I, I always, I always give them the, the idea, uh, or try to frame it ahead of time. I'm like, you're going to get this, you're going to get this report which is going to look really scary. Just talk to me and, and I'll explain all the scary words. Don't worry about it too much unless I call you directly. Um, is there anything that you maybe preface before you go through with an image with somebody so you don't, so you don't run them into that whole, uh, imaging finding, um, scariness type of stuff?

Yeah. Well, usually when I send somebody for imaging, uh, I'm the first one who's reporting the findings to them. And so, uh, so that, that's a nice thing because I have the ability to, rather than having to deprogram them from what they heard, they're hearing it from me for the first time. And so I'm able to communicate, uh, to patients. And what it's really important for me is, is always when I send somebody for imaging, I always read the, the films myself, not, not films anymore. Now it's all online, but I look at the images myself so they can have that much more confidence that what I'm telling them is something I assured I I've looked at the images myself.

I'm not just, uh, depending on the report, uh, that goes a long way as well. Oh, good. It's funny when you said filmed, actually. So my, my dad's a dentist. He's been practicing since I was, I mean, probably 25, 30 years now. And so he has these, all these old paper files. And so in dentistry, you have those little tiny x-rays. Yeah. And so he's trying to figure out how to get rid of the darn things, but each file is probably about an inch thick. It's just a big old space collector in the office. Yeah. Um, well, I, I love that you, you've created the book and everything. Cause, cause I'll, I'll tell you in all honesty, like with this, with this podcast, we have, I mean, there's about 1500 listeners consistently to each episode.

And so over the last, I mean, my, my adventure of learning like what I needed to get better at is really started to spike a little bit more over the last three, four years. And as I started to learn the things that I didn't know, I started really questioning why the hell I was doing the things that I was doing. Um, and, and even some friends like close friends that who are, who are chiropractors, I, I tell them like, look, you should, you should read the crisp books. You should go to maybe a McGill course, maybe, uh, investigate neurodynamics. And I'm actually startled by the amount of people who are just, they just want to have their business run.

They don't want to, they don't want to shake the boat. I think, um, in contrast, other people are very open to doing it. And, and, uh, uh, uh, your, your journey of, of kind of learning, uh, other things that you didn't know is actually, it's, it reminds me of myself a little bit, but you're probably way, you're way more advanced than me. But yeah, well, my experience with the books is that they, they, uh, certainly, um, reading the book and, and, and learning the material and, and understanding it, uh, will help people who really want to be excellent. Clinicians as, as, um, as, um, high quality as they can possibly be, it will help them to be that, uh, those who may be not, may be not as, um, as aspirational as regard to things like that, but they want to run a good practice.

They want to run a good, efficient practice. This will help them as well because it, it, it focuses not on not just, um, not just, uh, um, using an evidence-based approach to the patients, but it also, and applying the biopsychosocial model. But it also focuses on doing this in an efficient way in a really busy practice, um, and, and also in a, in a, in an efficient way, uh, apply the, um, the principles of cognitive behavioral therapy and acceptance and commitment therapy, uh, not doing psychotherapy, but rather, uh, informing everything that you do based on the principles of those psychotherapeutic, um, uh, uh, schools.

So, it, it, you can do it in a really busy practice and you can do it in a high, high quality. Yeah. I think definitely the, the speed of, of doing is, is an important part and that'd be probably a barrier for, for some clinicians to want to be able to implement something like that, you know? Yeah. Um, I, I'm actually interested. I, I, uh, heard from, you know, Michael Fanning. Michael Fanning. Uh, I think it's familiar, but it doesn't jump to me. He, he introduced me to, to, to Dr. Bears. Um, and that's how I got ahold of you actually. And so he was telling me about your, uh, um, the, the course, the, is it one year course?

Um, can you tell me more about that? Like what's, what's something like that entail for the, for the, uh, primary spine physician? Yeah. So he's probably talking about the primary spine practitioner training. What we're doing as part of the, the, um, uh, implementation of high value spine pathways is, uh, bring this new practitioner type to the healthcare system. That new practitioner type is the primary spine practitioner. This is a new, a new, uh, uh, healthcare practitioner basically that serves as primary care, uh, for patients with back or neck problems, cervical disorders, low back disorders.

Um, and so this is a, you know, this is not just a, a really good spine doc. Um, it, it is a, uh, a defined role in the healthcare system. And so to, uh, fully implement that we have developed, um, um, I and a whole team of people have developed a training program that, uh, was one year and it helps people to gain the knowledge and skills and ultimate, ultimately certification, uh, to function in this new innovative role as the primary spine practitioner. And the primary spine practitioner, it, we, the, uh, the, uh, the other thing that we're in the process of doing, in addition to training practitioners to be, to serve in this new role is take this new role and place it into an integrated spine care pathway by which everybody has a clearly defined job.

This is the, this is the pathway that I implemented here in Rhode Island. Everybody has a clearly delineated, delineated job and the primary spine practitioner serves as the hub of the wheel. That is, they're the first person that, that patients with, uh, low back pain or neck pain or thoracic pain sees. And then they're able to manage the majority without the need for referral, but they also are able to differential diagnose. They're able to determine who needs imaging, who doesn't, who needs to see a medical specialist for diagnostic purposes, who doesn't, who needs, um, acupuncture, behavioral health, um, physiatry, injections, surgeon, et cetera.

Most of whom don't need any of those things, but it's up to the primary spine practitioner to determine who they are, what they need. And it, and those who do need those things following up with the patient to keep them on, on track toward resolution of the problem as quickly as possible. And so serving as captain of the spine care team. So, um, so the training is, um, at, is through the university of Pittsburgh. So they, uh, they, they have a certification process by which they can train practitioners to serve in this new innovative role to get into the program. Uh, the, uh, the entry person has to have a certain level of skill, knowledge and skill going in.

And so as a result of that, the majority of people that we've trained and so far I have, I and university of Pittsburgh in total have trained for four or 500 people. And almost all of them are, are physical therapists and chiropractors because they're the, they're the professionals are most likely to have the basic knowledge and skills that they need to be augmented to become a PSP. And so is, is something like that, is that travel to Pittsburgh, live in Pittsburgh for a year or online? And then, uh, uh, some touch points along the way. Yeah, it's, it's online and touch points along the way. There's, there's, there's, it's four live, uh, units, four units.

Each unit is partially live and partially distance. Much of the material is distance. Uh, and right now, uh, so far the, um, live has, have all been in Pittsburgh at the university, but the plan is to bring it to other locations, uh, so that we can, you know, bring the course to people. Rather than having people to have to travel to Pittsburgh necessarily each time. Okay. Um, and so I'm, I'm curious with, I guess I'll, uh, I'll, I'll ask this question first. The, I'm, I'm thinking about with, so my experience was when, when I first started, got out of school, I was, um, more heavily involved in ART.

And so the cool thing was at least that, um, people would call and they would be like, Hey, do you ART? I was looking for it and this is what I found you on the site. And so the, the, I feel like they do the same thing with FMS and TPI and like all these acronym ones. And, um, it seemed like they've done a really good job of promoting the methodology amongst the general population. Is, um, is that something you guys are going to consider doing? Cause I would love if someone called and said, Hey, are you a primary spine physician? Yeah, come on in, you know? Yes. Yep. Yeah. And that's what, uh, we're doing.

We're working together with, uh, my other hat is, uh, with the, uh, uh, primary spine practitioner network, which is a network by which we provide support and, uh, ongoing education for people who are primary spine practitioners or aspire to be primary spine practitioners. And the, the, the, uh, task there is to bring a recognition in the healthcare system of this new innovative role. So that the people who, you know, gain the certification, they've gained the knowledge and skills and have, have become really high quality, uh, where on the other hand, the, through the primary spine practitioner network, we're bringing that value to the healthcare system and helping the healthcare system to see the, the, the value of, of this new innovative role in their system.

Mm-hmm that's, yeah, that's good. Cause I think there's, um, I was talking to a listener the other day and they were, they were kind of venting a little bit about how frustrating it is that it's, it's, uh, we, we don't get driven people if we're better. And not, not to say that it's like all about the money, but it's, it's kind of like the people who are really good at business marketing, they're also their skill sets as, as a practitioner are usually much lower in my opinion. And the other ones, it's like the academics, it's like they suck in business. And so it's kind of like the, the drive to become better also results in less income.

And so it's, it's, it's, it's, it's, it's, it's, it's, it's only been 30 years for me. No, not all of that time was, but that much of my early career, that's exactly the, the, um, the dilemma that I was faced with until I got more efficient. But for a long time, that was the case and, and it shouldn't be that way. And the system is designed for that, that especially in spine, the system is designed to incentivize bad care, uh, and to dis, the disincentivize good care. Well, that's not a tenable situation. We can't continue, which is why we have, we have a situation in spine that we have the, uh, most inefficient, uh, inefficient, expensive, and messed up, low value, low quality environment.

Environment, in, in, in all of medicine, there's no area in healthcare that is the, anywhere near the mess that we have in spine. Mm-hmm. Um, I don't know if I can ask you to, what do you mean by the worst? Is that something I, I don't want to, yeah, I don't want to demonize people. I don't want to throw you into the, put heavy throwing anyone in the bus. But what do you think is an example of, what's a story, maybe a patient that came in where you thought, wow, this, this person just got put to the ringer. I really wish I had this person two years ago. Yeah. Okay. Well, uh, so, uh, a good, a good example, um, is, I, I, I can think of, uh, 1500 examples or more, 5,000 examples, um, that I've encountered.

But a good example would be, uh, a patient, I, I think this is one of the ones that I, I, um, include, I included in, uh, one of the chapters in volume two, um, that was a good illustration of, that's why that's the first one that pops into my head, is a good illustration of, um, the, the, the wrong way to go about managing patients with spine. So there's a patient that came to me and, uh, they had, uh, I don't remember all the details, but it, but it's in the, in volume two of the book, um, they had a neck, a neck problem, a neck and arm pain. And they had seen their primary care doctor, the primary care doctor sent them to a neurologist, uh, took him, took him out of work.

It happened at work, took him out of work, don't work at all, see the neurologist, stay out of work until you've seen the neurologist so they can find out what's going on. It was six weeks before they could see the neurologist. The neurologist sent them for an MRI and did an M M M G, uh, both of which subsequently I realized were completely unnecessary, but that, so that required another several weeks before they completed that followed up with the neurologist and said, well, you've got a degenerative disc, uh, and the, the, the, uh, the nerve test shows that you have nerve damage. You better see the neurosurgeon.

Another six weeks go by, sees the neurosurgeon. Yeah, you, you may need an operation, but I don't think you need an operation right now. Okay. What do I need? Well, you may need, I forget what exactly happened. They might've had physical therapy. Um, and whether, whether it was high quality physical therapy, I don't remember, but finally went back to the primary care doctor and now we're, we're talking, you know, three or four or five months completely out of work, not, not having been given any clear answers as to what the problem is. Not being given anything that any kind of understanding of what the problem is and how to understand and how to conceptualize what's going on.

And finally, the, uh, primary care doc says, well, I heard about this primary care, primary spine practitioner. Maybe you should see him. And that's when he saw me and I was, I was able to get him back right back on track, but it took an awfully long time, far longer than it should have, because I had to deprogram all those things that had happened for the prior six or eight months or whatever it was. Uh, when, if they had seen the upfront, this thing, I'm, I'm very convinced that the problem would be a distance, distant memory by the time the web, whatever the date arrived that when they saw me by that time, if I had seen them in the beginning, probably by that time, the, whatever the problem was would be a distant memory for them.

Instead, it's a, they're, they're, they've descended into chronic pain. They are hopeless, feeling hopeless and helpless. They have pain that should have been dealt with effectively a long time ago. And that should never, ever, ever have happened. So what I'm, what I'm hearing is then the, the initial contact point, and I'm just probably why you made the PSP is the quarterback could have navigated them better, but, but also along the line though, too, couldn't the, all the other specialists could have stopped this whole thing. Yes, they could have stopped this whole thing, but they, they, they, they don't have the, uh, knowledge and skills.

I don't, I don't want to sound disparaging to people, but we all have our knowledge and skills and neurologists by and large, neurosurgeons by and large. And I'm not going to, I don't want to paint them with a broad brush, but they're skilled in a, they're skilled and knowledgeable in a very defined area, uh, and not in case coordination, not in non-operative management, not in, uh, um, uh, teaching people self-care, not in helping give people a clear understanding of, uh, the, um, the, the nuances of the problem. Um, this is not their field, so we, we shouldn't expect them to be knowledgeable, not knowledgeable and skilled in that area.

Cause that's not, that's not what they're there for. That's not what they, their value is. So, but we need somebody who is, who can play that role. And that's why we developed a primary spine practitioner. Good. This is not a knock on the, the neurologist that he saw was probably very, very good neurologist. The neurosurgeon was probably a very, very good neurosurgeon. They did their job. The problem was the patient never had seen them at that time in the first place. Right, right. I totally agree. Yeah, I think, um, definitely quarterbacking, uh, better on that initial triage front would have been, would have been better.

And even if that general practitioner didn't know what to do, at least they know who to send to for a nice comprehensive triage and the, and then that practitioner can make a better call of what's needed. Right, right. Exactly. So that's why in the system, you know, the, in the ideal world, the primary spine practitioner should always be the first person and the first person that anybody sees who has a spine problem. Uh, you know, the analogy I've used is the dentist of the spine. So, you know, somebody who has a toothache doesn't go to their primary care doctor because we already have a defined professional who serves as primary care for oral health.

That's the dentist, the general dentist. And so ideally the PSP would serve like the general dentist, except they'd be the general practitioner for spine. But in reality, people are still going to go to their primary care doctor if their back or neck hurts because they trust that person. So that's why it's so important that that person understands, uh, what the, how to best manage that person and how to best direct that person whom they should be referring them to whom they should not be referring them to, uh, um, when imaging is necessary, when imaging is not necessary. And this is the value of the primary spine practitioner as serve as that resource to the primary care practitioner.

And I'd venture to say that, that probably, I mean, that primary, primary spine practitioner would probably be able to manage 90% of the cases that walk in the door anyways. Yes. And that's, again, the, the healthcare system is looking for higher value and more efficiency. So you can't get more efficient than having a single practitioner who can manage the vast majority without the need for referral. I mean, that's, that's the ultimate of, of, uh, efficiency. So I'll just play devil's advocate on this real quick. Cause I think this is, this is probably one thing that when people encounter like, um, you know, the idea of going through like the, uh, the one year program and so on, they might say, well, I'm already a spine expert.

Why would I do this? Any, any thoughts on that? I've, I've heard it many, many times and in, I can say with in almost every single or virtual or, um, um, um, literally every single time, anybody who's, who's told me that who then entered the program would come to me later and say, I realized I was wrong. I wasn't, I thought I was a primary spine practitioner, but I'm not. So believe me, uh, and, and, uh, I'm saying this because I want to be honest and upfront with people. If you went to chiropractic school or you went to physical therapy school, you did not, you were not trained to be a primary spine practitioner.

You were not given all the knowledge and skills to serve in this new innovative role. You were given many of the skills that are needed, but you weren't trained with everything that is needed, uh, or even close to anything that was, that is needed to serve in this new innovative role. So, and I shouldn't say not anywhere close by and large, most chiropractors and most physical therapists or at least physical therapists that have had additional training in spine, they have most of the skills that they are needed, but they are not able to play that new innovative role. And it's similar to, um, uh, a, a primary care physician who, um, you know, I was talking to a friend of mine who's, um, in a residency at the university of Pittsburgh and the, in physical medicine, physiatry.

And he was telling me about, we were talking about primary care physicians and he said, you know, I, I went through four years of medical school. I went through a full year of full-time, uh, in internal medicine. And after all of that, I am not even close to being able to serve as a primary care physician. I don't have all the knowledge and skills that are needed. And it's a similar analogous situation with the graduate of chiropractic school or physical therapy school. They have gained a lot of, of, of knowledge and skill, but they're not there yet. And, but they can be there if they really want to.

Right. I, and I would agree with that. I think even to, to, to second on that is, is not, it's not just that they haven't had the repetitions. It's just, it's just the knowledge of what to do. Um, and, and so I can be a testament of like five years out of school, I was getting more repetitions and not until I realized some of the things I didn't know that I realized that I was doing things very poorly for those five years. And so it was kind of a hindrance on my growth, I think. Yeah. And the other, the other aspect of that is being trained to, um, utilize the knowledge and skills that you have in ways that you weren't trained to use them.

So the primary spine practitioner, their, their job, uh, involves utilizing a lot of knowledge and skills that these people already have, but they haven't been trained how to utilize that knowledge and skill in these new innovative ways. What's, um, just because the listeners might be wondering now, what's the most common thing when people come in as into that program that is like an aha moment to them that maybe they're learning to use the skills they learned in school a little bit better, or maybe it's a new skill set where they're like, well, crap, I, I'm so glad I came. Um, there are several things.

Um, one is opening their eyes to this new innovative role. You know, what, what, what a, what a primary primary spine practitioner is and, uh, realizing what it really is rather than what they thought it was going to be. Number one, number two, a big aspect is the, um, the, an understanding of and ability to manage the psychological perpetuating factors that are so important in patients with spine related disorders and really being able to, uh, again, identify those things and to effectively manage those things, um, that the vast majority didn't learn at all in school. Um, they mostly were trained in a somatic model, like, like all of us were trained in a somatic model.

And so the biopsychosocial model with a term that everybody has heard, but virtually nobody has really learned it, uh, what it really means and how we can really understand the biological, the psychological, the social factors that are contributing to each patient's problem and how we can turn that into a diagnosis and develop the management strategy that is maximally able to address those individual factors that are affecting each patient. So I think that's a big aha moment as well. Um, and then the third one is if I may say so crisp is that utilizing, you know, all this stuff, all this knowledge and skills, this information that are all in my head, what do I do with all this stuff?

Well, crisp provides them with an efficient way of taking that and honing into and sharpening it so that you can utilize it maximally for the benefit of your patients and be able to do it in a really busy clinical environment. I thought you were going to say crisp was a nice refreshing way because it was crisp. Yeah. Well, I like that. Um, well, yeah, that is, it's great. I think, uh, actually they're starting to use, so crisp, they're starting to use the, the, the methodology at SCU, I think. And, um, I thought, did Western states use it years ago? Um, I don't know. I know SCU, um, using it now and a few schools have adopted it, um, big time.

Others are in, in process. So I, I've been teaching at different schools to help them to, you know, maximize, maximize the utility of crisp in their training. Um, and so there's a lot of interest now I'm going to be at Logan in St. Louis in October and I've been at, I'll be in, uh, at NYCC, uh, New York Chiropractic College in September. So there's a lot of interest in utilizing this technology to, to improve the efficiency. So is it safe to say there's, there's no back pain at all in Pittsburgh anymore? Uh, no, we don't want that to happen. We'll have to find a job. They have to be able to work now.

I mean, I don't think that day is coming anytime soon, but if we, if, as long as people getting the pain, the, the, the, the care that they need, then that's the key. Yeah. Um, how can everyone reach you, um, if they're looking to learn more about you or buy some of the books or figure out about the program? Yeah. Well, they can go to, uh, my, uh, website, uh, crisp education and research if they want to learn more about me, about my work and about the books. So crisp education and research.com, uh, then if they're interested in the, the PSP movement, I also recommend them to the primary spine provider network.com.

That's the, that's the company that I'm a part of that is, is, um, advancing the PSP movement. And then if they're interested in the PSP training, go to the, uh, university of Pittsburgh and their PSP page, and they'll find out more there about that. Nice. I'm, I'm, I'm really glad you didn't call it the better medical movement because that would be abbreviated as, as BM movement. Um, and so is there anything that you think I needed to ask in this podcast that I didn't, that would be a value to somebody? You covered it really well. Um, and, um, I guess if it, to, to just kind of, uh, encapsulate things to, to bring it all together, uh, I'm hoping to, uh, get people excited about this, this movement.

Cause this is, uh, this is not just a, um, you know, a training program and, uh, learning new skills. This is a movement. Uh, this is a movement that is designed to, and I'm very confidently, I'm very confident will, uh, revolutionize how spine care is given, is delivered in our healthcare system. And so I would love people to jump, jump on board on the movement because it's, it is very much a movement and it's, and unlike other areas of healthcare that, you know, there's a lot of new things going on. There are not too many things that really, um, can be defined as a movement. Yeah. I'm really glad you didn't use better medical now.

Yeah, yeah, no, it is a movement. Well, that's awesome. Yeah. I think, uh, exciting things to come for sure. Um, you're going to have a lasting legacy then you'll be the guy that started the movement. Well, thank you. I didn't start it though. Uh, Dr. Scott Haldeman started it to, to, to give a credit where credit is due. Dr. Scott Haldeman, you may know who he is. Uh, he's the godfather of the spine, uh, primary spine practitioner movement. Um, but I, I would like to, I'm glad to be able to play my, my little role. Nice. Well, thank you so much for being on. Um, this is amazing. This is great.

Thank you. I really appreciate you having me. Murph, thanks so much for being on. That was, that was an amazing conversation and it was great getting to know you. So you're, uh, I can tell you you're, you're, you're probably very funny and, um, interactive with your patients and I can see why they get that rapport. And so thanks so much for also to, um, helping out with pushing our, our movement forward. And, uh, hopefully that, that piece PSP becomes the forefront of the triage for, uh, spinal based conditions. So, uh, I'll do my part to try to push that out there. And so, uh, everybody, uh, if you have not already done so, can you please review the podcast for me?

And I say this because I'm not trying to like, like, like I've said before, I don't make any money on this podcast. It's a passion thing. And so please validate that I'm doing the right thing and let me know your feedback. Let me know what you love and hate about the podcast via iTunes review. Hopefully it's a five star, but it didn't have to be. And also share this too with a colleague who you drive to school with, who needs to hear this information. All right. Whether you're a PT, a DC, an ATC, please share this with somebody. The only way this really thing really gets out because you're going to see on Instagram, I don't really, I mean, every, every Wednesday I'll post part of the, uh, of the podcast for the day, but I really don't do much advertising other than that.

And so currently we currently for the probably for the past couple of months, we've been sitting around 1500 downloads per episode. I want to spike that to 5,000 per episode. Can we do that? I don't know how many chiropractors and PTs are in the U S but can you all share it with one person? One right now, please share with one person who you think would be interested in. And please subscribe to the podcast that would help me out immensely to validate that I'm actually doing the right thing and trying to improve the profession. So you notice that just people, people just like, uh, the Murph that, uh, we have a passion to, to help improve, um, patient communication, patient outcome, and help make our job as healthcare providers easier.

And so the only way you can really get that information out there is by word of mouth because we're, we're crappy or an, at least for me, I'm, I'm a crappy marketer. And so I'm not going to, I'm not going to go through and do Facebook ads and Instagram ads and all that stuff for the podcast. It's all about if you can share it with somebody. So please do that. And I'll see you guys next week. Lead people better than how you found them. If you're dating, date an Eagle Scout. I'll talk to you guys soon.