 Exploring chiropractic, episode 34, primary spine care with Dr. Donald Murphy. Does chiropractic training prepare students to be primary care practitioners similar to the family medicine doctor? The answer is emphatically and absolutely not even close. Hey guys, I want to tell you about Backblaze.com. Backblaze is unlimited data backup for your Mac or PC for just $5 a month. It's unlimited files, unlimited file size, unlimited speed. And get this, it will back up all of your attached external drives. That's right, so not just the stuff on your computer, but you've got your old photos, your old movies. And you can back up everything that's attached to your computer. Check it out exploringchiropractic.com slash Backblaze. Welcome back to Exploring Chiropractic, the only student chiropractic podcast. I'm Dr. Nathan Cashin. My guest this episode is Clinical Director of the Rhode Island Spine Center and the Director of Primary Spine Care Services for the Care New England Health System. He also serves as clinical assistant professor in the Department of Family Medicine at the Alpert Medical School of Brown University, the professor at Southern California University of Health Sciences, and adjunct associate professor in the Department of Research at New York Chiropractic College. You may have heard of the clinical reasoning in spine pain textbooks which he has authored, and I'm very excited to bring him on the podcast to discuss his background in chiropractic, the concept of primary spine care, and more details about the CRISP protocols. Dr. Murphy also answers some listener questions. I hope you enjoy this interview with Dr. Donald Murphy. Dr. Murphy, thank you for joining me on Exploring Chiropractic. It's a pleasure to have you on. Thank you for having me. I was looking through your CV. One of your previous interns or preceptors, I'm not sure what you call it, Dr. Brendan McCann recommended I take a look at your CV, and I haven't been able to get through the whole thing. It's quite a volume, but the one thing that stood out to me is you started in acting, is that right? Yes, I was a theater major before I switched majors to pre-chiropractic. So what took you from acting to chiropractic? Well, my first two years of college, I was again a theater major. I was studying acting, and that's what I wanted my career to be. But as I was going along, I decided that I loved acting, but I didn't have the level of passion that is required to live the kind of life that an actor has to live while they're struggling to make it. So I wanted something more steady and more stable, and so I actually took a year and a half off after my first two years to find myself before deciding to go back to school and become a chiropractor. Did that time often involve any world travel, any type of voyages that helped you find yourself, or was it just taking a break? Well, not world travel, but country travel. I grew up in New York, and I was living in New York, and so I moved to California, which in the 70s, early 80s, that's what one did when one was finding oneself, moved to California. So I lived in Newport Beach, California for almost a year, because kind of working and living, and again, I didn't go out there to set out to find myself, but that's what ended up happening. I got it. So from there, how did you get into chiropractic? Did you have a miracle chiropractic story, or was it just something you were aware of? Well, I came back to New York after living in California, and I had a friend who was just getting ready to start a New York chiropractic college. So he would talk to me about chiropractic, and it sounded really interesting. I was always interested in health and fitness, and so I was naturally intrigued to anything related to health, but also something natural and focused on an act of lifestyle and that kind of thing, and so I became intrigued, and then I developed a shoulder problem, and so my friend encouraged me to see a chiropractor about it, and the chiropractor was able to help me, so I said, okay, this is something that I want to go into. Interesting. The way you describe that, it almost sounds like kind of a spontaneous decision. How much time did you deliberate on going into chiropractic? Well, we're going back a couple of years, so I'm taxing my memory a little bit, but I don't think it took very long. Once I decided, okay, I want to have a direction, and I started talking to this friend and had the chiropractic experience, it was pretty quick that this is the direction I wanted to go in. I find that interesting because recently, I heard a very similar story. I don't know if you were familiar with Dr. Lester Lamb, who's well known out here at Western States, and he just passed away, and so at his memorial they were playing a video, and he told a very similar story. He was in the military, the Peace Corps, he came back, didn't know what to do with himself, and a friend was enrolling in chiropractic school, and he kind of said, okay, I'll do that too, which seems very different to, say, my experience, where I probably deliberated for about 10 years before I actually started school. Yeah. So you went to New York Chiropractic College. Yes. And after that, I understand you did some postgraduate training. Yes. I first did the postgraduate training in certified chiropractic sports physician. I got that certification, which was, I think, 100 hours or something like that. And then I started the neurology diplomate program, and that was a three-year process, and I earned my diplomate in chiropractic neurology, quote-unquote. And during that time I became very passionate about neurology and neurodiagnosis, and so I supplemented my diplomate studies by making myself a pest to the attending physicians at the local teaching hospital in the neurology department until they let me come and do rotations with the neurology residents. And so I spent over 200 hours doing rotations with the residents in the various clinics, the neurology clinics, and really getting a great education in neurodiagnosis. At this time you had already graduated. Were you in practice? Yep, I was practicing at the same time, so it was a very time-consuming process. Yeah, and I find it interesting that you were able to, after some pestering, as you say, convince them. I think a lot of students really would love to have an opportunity like that, but I certainly have tried a couple of times and just gotten so much pushback or disinterest that it was hard to keep trying. What led to that persistence? Well, I think that what was very helpful to me was that I showed myself to not only be persistent to these folks in the neurology department, but also passionate about learning and sincere about learning. And so this was a teaching hospital, so the people who are involved, the attending physicians there are teachers, and as a teacher myself, and you can imagine because you said you taught yourself as well, teachers love to teach. And so there's nothing that a teacher loves more than to encounter somebody who's passionate about learning what they have to teach. And so I inadvertently appealed to that aspect of their nature and I think that was my biggest asset. What did you do other than doing the Diplomat program in neurology? And was that, by the way, was that through Carrick at the time or was this a different program? Nope. It was run by a guy named Dr. Joseph Ferrissie who I think still has a course running and it was through the New York Heart Practical College. Oh, interesting. I hadn't heard of that one. Okay. So outside of the Diplomat program, what types of things did you do to educate yourself to prove your devotion and passion for learning to allow you to get into these teaching hospitals? Well, in addition to and separate from that process of taking the neurology course and doing the neurology rotations, I was passionate about learning and I also recognized that in chiropractic school, whereas my education in New York chiropractic college was good, it did not provide me with what I really needed to know to help my patients to be an excellent diagnostician, an excellent treater of patients with the various kinds of problems they came in with. And so I realized that if I'm going to gain that knowledge, I'm going to have to do it on my own. And so I did, I spent a lot of time reading the literature and studying books and I traveled abroad to the Czech Republic on two separate occasions studying under Dr. Vladimir Yanda and Dr. Carol Levitt and I studied with them here as well in the States when they came here and studied under Dr. Janet Travelle and a wide number of people just trying to gather and gain as much knowledge and experience and skill as I possibly could. That would help me be the best as it turns out spine doctor as I could be at that time. I didn't see myself as a spine doctor per se. I saw myself as a musculoskeletal doctor but I realized as time went on and I'm sure we'll get to this that primary spine care was my real passion. Let's get into that because that is one of the big topics that I'm interested in at this present time. Explain for my listeners, what is primary spine care? Primary spine care is a new role that we're introducing into the healthcare system where in a practitioner, a primary spine practitioner plays the role of primary care for patients with spine problems. So this person needs to be capable of managing the majority of spine patients without the need for referral but also knowing how to manage the case, manage the situation, be the quarterback of the spine care team which means keenly understanding differential diagnosis, knowing when to recognize when somebody needs special tests or specialist consults, knowing and identifying when somebody needs invasive procedures such as injections or surgery or intensive procedures such as multidisciplinary pain management, recognizing when somebody requires psychological or behavioral intervention and following up with that patient to make sure that they maintain on track, they keep themselves on track toward resolution. So literally being the primary care practitioner for patients with spine-related disorders. So we mentioned before we started recording how there's kind of a spectrum between the schools, a lot of schools have different approaches and some of them really brand themselves as training primary care practitioners. But I have to say I have some reservations myself about whether the amount of experience we get really qualifies us. I'm curious what your thoughts are. Does the chiropractic curriculum as it stands provide deep enough training to allow students that are graduating to be that primary spine practitioner? To be the primary spine practitioner or the general primary care practitioner? Maybe both. I guess I consider them somewhat the same. In that you do need to have that broad knowledge of differentials and when to refer out. Maybe take one at a time. Okay, so does chiropractic training prepare students to be primary care practitioners similar to the family medicine doctor or the general internal medicine doctor? And the answer is emphatically and absolutely not even close. My primary faculty appointment is at the Medical School of Brown University. Most of my appointment is in the family medicine department. Most of my teaching is either family medicine residents or internal medicine residents. I get to interact with real primary care doctors and real primary care trainees training in real primary care. And chiropractic education is so far from what is required to be a true primary care doctor that it's not even worth having a conversation about except the fact that there are many chiropractors who think they are trained to be primary care practitioners and many schools who think they are training primary care practitioners. And that was my experience. Certainly my school emphasizes that but I remember having a discussion at one time with one of the faculty that, you know, when I was an undergrad I had a roommate who was a nursing student. This was pre-nursing and he had to do, I think it was at the time 100 sets of idols. Heart rate, blood pressure, maybe even listening to heart sounds although I don't think nursing students do that very often. But in my experience going through chiropractic school I think our numbers were 10, 20 sets of idols and I just didn't feel like I was getting the experience with it that I needed to be able to confidently tell other doctors and patients that I can be your primary contact. Right. Right. And if you speak to people in the general healthcare community even those that are open to chiropractors if you even mention chiropractors as general primary care practitioners you'll either get a blank stare or a hearty laugh. Or very concerned looks. Or very concerned looks at that very good point or very concerned looks because that is so, the notion is so far-fetched. So what about chiropractic students coming out of their three or four years of training being prepared to be the primary spine practitioner? Okay. So now we're talking. So chiropractic training prepares students to be prepared to become primary spine practitioners. Okay. Okay. So the chiropractic students gain a lot of the basic knowledge, a lot of the basic skills that are necessary to be a primary spine practitioner but are not sufficient to be a primary spine practitioner. So additional training, additional knowledge, additional experience is necessary to really become a bona fide primary spine practitioner. But of all the healthcare schools out there, chiropractic schools are the closest to providing their students with the knowledge and skills that are needed to become primary spine practitioners. But I have the opportunity to, I have a regular externship at my facility and so I've been training interns from several different chiropractic schools for the past 20 years or so. So I have a pretty good experience and these are the most highly motivated chiropractic students because they're willing to travel and find lodging to spend 10 to 15 weeks with me. The most highly motivated students and they're not, they're not, I shouldn't say they're not close. They are fairly close but they do not have the knowledge and skills to serve as a primary spine practitioner. They're closer than anybody else in terms of healthcare schools but they don't have all that it takes. What will that training look like? Is this another diplomat program of 300 hours? How will a student or current practitioner become prepared to be a primary spine care practitioner? As it stands now, I'm in the process of we're just finishing up and getting ready to launch a course through the University of Pittsburgh that is a one-year course that provides additional training to be able to serve in this role of primary spine practitioner. It consists of five modules, I'm sorry, five units we call them, five units each unit consists of a weekend seminar and a series of online courses. It takes place over a year and there's a unit exam at the end of each unit and then there's a final practical exam at the end of the course and this will be the beginning of the official certification process for primary spine practitioners. So we're doing it through the University of Pittsburgh but also it's in a loose partnership with Southern California University of Health Sciences which is where Los Angeles College of Chiropractic is. And so this is the beginning of the formal certification training of primary spine practitioners. Ultimately primary spine care training has to be, what will have to be a residency-based training but that's down the road, that's what we're looking toward but you have to start somewhere so this is where we're starting. Will this training be available to current students or is this only a postgraduate opportunity? It's designed for postgraduate so to be eligible for the certification one has to have graduated from a healthcare institution and be able to have the basic knowledge and skills required to then be augmented to become a primary spine practitioner. Will students be able to start the coursework before they're graduating? Currently the, and I'll preface this by saying that I'm responsible for the content and the delivery of the information. I'm not an official at the University of Pittsburgh so policy will be established by the university but currently the plan is for this to be a postgraduate course just as a medical graduate who wants to become an internal medicine physician or a neurologist will need to graduate medical school and then go on to additional training. It's the same thing, you need to graduate from chiropractic school in order to then go on and continue your training to be a PSP. The University of Bridgeport recently held a panel that was shared on Facebook about the primary spine practitioner initiative or goal of many to kind of start this specialty and needless to say there's a lot of controversy I guess you could say that might be a strong word but a lot of people have concerns and one of the main questions is will labeling chiropractors as primary spine practitioners limit their scope? That's the most common concern that I hear from chiropractors that it will be limiting and it's kind of funny because for one thing chiropractors currently see about 10% of the population pretty much 100% of the population have spine problems at some point if you consider back pain, neck pain and headaches so I asked the question which is limiting 10% or 90% so it's really kind of amusing to consider this limiting the other thing I would have to say is that I've been practicing as a primary spine practitioner for pretty much most of the last 20 years I've been in practice 29 years and I'm now in charge of a program an integrated spine care program at a large hospital system and where primary spine care services are the main focus of the program and I love seeing patients with spine problems spine care is my passion I try to avoid extremity problems even actively trying to avoid seeing patients with extremity problems I have plenty of them come in I have patients come in referred by ear, nose and throat doctors who have oral facial pain I have patients referred in who have shoulder pain, knee pain and I love seeing the oral facial pain patients but the extremity patients I don't have much of an interest in that and even trying to avoid those things I can't avoid them, I get plenty of them if I wanted to pursue seeing more extremity problems I would be inundated with them so in reality if a chiropractor establishes credibility in their core area of primary spine care they will then be able to leverage that credibility into other areas so not only is it not limiting it's expansive and that's what has been my experience Very interesting so you've mentioned how eventually the goal is to have this almost as a residency and I have a listener question this is from Isaac who asked what is the best path to getting more DC's hired in the mainstream healthcare delivery system That's a great question from Isaac and it's not an easy one to answer however basically for a chiropractor to become involved in mainstream healthcare it will be as a spine care doctor or it won't happen at all with the exception of sports medicine so sports medicine chiropractors several chiropractors have had success in incorporating themselves in the mainstream of the sports medicine world so that's a niche that's available to chiropractors that many have taken advantage of but aside from that if one wants to be a part of the mainstream health system it's going to be as a spine doctor or it's not going to be as anything so and what the healthcare system is looking for is people to be able to play innovative new roles that provide value in certain areas of medicine that currently high value is not currently being provided and so the healthcare system has never been more open to I hate to use the word alternative but alternative if I may use that term mechanisms of delivering quality healthcare and so probably the most expensive least effective and messy is of all of medicine is spine and so the opportunity exists but what we have to realize is that as it stands now saying I provide chiropractic care that means something to us it means something to our patients but in the wider healthcare world they don't quite understand what that means which is why I think primary spine care has a resonance it resonates with people in the healthcare system because that's an area that is where there's a recognized need you told me that you did your sport certification and I was just certified and I did the masters in sports medicine here at western states and that certainly was my original interest in chiropractic I was active as a teenager and that's part of my first introduction to chiropractic and I appreciate that you shared that sports chiropractic is one of the other ways that chiropractic can become more widely accepted do you see and this is kind of taking another listener question who asks what is the best way to start integrating this spine practitioner into a more traditional rehab or adjusting based office and I just want to add to that how can a primary spine practitioner continue say their passion for sports or any other interest that they may have in chiropractic well you know the primary spine care and interest in sports medicine are not mutually exclusive I mean for one thing there are plenty of sports injuries that involve the spine and certainly having credibility as a spine practitioner will be helpful in terms of being a recognized expert in those kinds of problems but again having a sports oriented primary spine practitioner I don't see that being mutually exclusive at all excellent that makes me very hopeful now you also have written two textbooks on spine pain on this idea of the spine practitioner what led to writing these books well as I went along my journey of recognizing the limitations of what I knew and what I was able to do in helping people overcome spine related problems I started reading the literature I started taking seminars I started studying abroad etc and I realized that there was a lot of good evidence-based information out there but it was very disparate it was all over it and there was no connection between all of the different models of care all of the different information and research that was available in the field and so I said we need to have a way to bring this all together into a cohesive model that can be applied in a busy practice environment and so as that evolved I ended up writing a textbook in the late 90s called conservative management of cervical spine syndromes and that began the process of my culminating all of this information into a cohesive approach as I developed that approach I said well you know does this approach really work in the real world and so I started doing observational studies looking at groups of patients and treated according to this approach which I had a name for it that I won't bother you with because it was kind of cumbersome name but observationally at least what I found was that yeah patients seemed to benefit from this approach and so as I started formalizing this process and started, I wasn't alone in this conceptualizing this primary spine practitioner role I and a team of others who are co-authors on my original paper started culminating this new role this primary spine practitioner this melded well with the clinical approach that I was putting together that considered all of the biological, psychological and social factors that can contribute to the spine pain experience into a diagnostic and treatment model that could be again applied in a busy practice environment so I developed this clinical reasoning process by which the spine practitioner can again consider the multiple factors that can contribute to the spine pain experience figure out which of those factors are contributing in this particular patient's case and how can I formulate a diagnosis from that and then formulate a management strategy that is most likely to respond positively to the diagnostic factors that I identified and so I call them the CRISP protocols clinical reasoning and spine pain and so I ended up writing these two books one is primarily focused on the low back and the other is primarily focused on the cervical spine with a chapter on the thoracic spine and these became basically the operations manual for the primary spine practitioner as a matter of fact the second volume of the textbook has two chapters on case studies in primary spine care where I go through 18 cases and I go through the process from the first presentation of the patient how the primary spine practitioner would look at that patient, evaluate them interact with them establish a diagnosis decide on a management strategy and then guide that patient from having this pain disability and suffering experience to resolution of the problem and all of the different things that has to happen on that process again spine pain is multifactorial there are biological factors somatic there are neurophysiological factors all occurring in the social context in which the patient lives and so the primary spine practitioner has to be able to look at all of those things figure out which of those factors are playing a role in this particular person's suffering and how can I address those and help them overcome this problem whether it's things that I can do myself whether it's things that I need to obtain from other members of the spine care team but I am the one who's responsible for guiding the patient along that process toward resolution and so the books put that process together clinical reasoning and spine pain or the CRISP protocols put that process together and help the spine practitioner utilize this clinical reasoning process in practice the first volume I've already read through and it certainly helped me clarify just the framework in my mind about how I was approaching a patient and I came out of school I think knowing all of these different pieces I certainly knew a lot about diagnosis a lot about treatment soft tissue adjustment but I didn't feel like I knew how to fit them all together in a cohesive way I think that's really what these textbooks have helped me with and I think a lot of students have had that same experience so I really appreciate it and that is exactly what it was designed for is to I have these skills I have this knowledge how do I apply what do I do in what situation when and how do I make sense of this whole situation and how do I respond utilizing the skills I have you mentioned your co-authors and some other I noticed you you had a long list of acknowledgments in both textbooks and I'm curious who you've already mentioned Yand and Levitt who are some other influences that have really informed your practice and guided you along the way well one of the biggest ones in terms of the overall view of healthcare and primary spine care and where the PSP can fit into the broader healthcare world is Scott Haldeman he may be familiar with him he he helped me to crystallize the evidence based approach to spine care but also fits in the broader scheme of the healthcare system he was extremely influential and still is on my thought process with that regard and again my learning journey over the past 30 years has been so eclectic that there are so many different people that influence that process but certainly I mentioned Dr. Joe Ferrissie who taught the neurology course I learned a tremendous amount about neurodiagnosis from him and he helped me to see where neurodiagnosis plays as an important role in spine care I mentioned in the book Yand and Levitt I mentioned earlier the scheme of people that I work with implementing the integrated spine care pathway that I'm currently implementing in the hospital system where I work that have been very very helpful to me in broadening my view of where primary spine care fits in to the wider spine care world people like Dr. Brian Justice Dr. John Ventura Dr. Kowski Dr. Tom Nooner they're my partners in this process of bringing this integrated spine care pathway to other hospital systems payers and other healthcare delivery systems where primary spine care services and integrated primary spine care pathways can be implemented and really respond to the value model that is so important in the coming healthcare system Michael Schneider Dr. Michael Schneider is my partner in the course at the PSP course at the University of Pittsburgh he's been a very important person in this process Mark Laslet is a physical therapist from New Zealand who has done so much work on diagnosis identifying pain generators in the spine and using an evidence based approach to in a credible way identify pain generators and Robin McKenzie who developed the McKenzie approach also has been very influential in that regard in terms of diagnosis and helping to bring to teach people how to take care of themselves boy there's such a large people that have been an influence and I hate to leave anybody out well I definitely will refer everyone to the acknowledgements in both textbooks if you don't mind I'd kind of like to come back to Dr. Scott Haldeman because I am a big fan he's got world spine care which I'm a volunteer with but as I look at I guess my influences or the people who I look to and Dr. Haldeman certainly is there you have made the list recently with the textbooks I'm noticing some similarities and I read through Haldeman's biography and two things I would I guess I would like to ask you about number one you seem to be involved in a wide range of things and I'm curious how do you personally manage to do so many different things and to do so productively oh wow well I think I'm very good with organization and time management so that's really the key to getting a lot done in a normal 24 hour day I'd love to have my days be 36 or 48 hours long but unfortunately they're 24 hours like the rest of us but being organized and being a good time manager is extremely important and you know I'm driven by passion and that's the biggest thing if you have passion you figure out a way the other similarity that I see and again going back to your CV with a long list of articles is that again both you and Dr. Haldeman have published a lot is writing something that you've always enjoyed doing or have done throughout your life yes ever since I was a kid I was a writer I used to write stories I used to write believe it or not this sounds awfully geeky but I used to write book reports if we were assigned a book report in elementary school I would write three instead of the one that was I just always love to write and that was just something that's in me and so that certainly has helped I talk to a lot of people that have trouble writing sitting down and writing what's on their mind and I just happen to be the type of person that writing comes very natural to me I definitely am the opposite the book reports were the hardest thing for me to get through in elementary school and I remember one day in particular we had a journaling assignment where we just had to write what did you do over the weekend and I ended up staying at least an hour after school because I just couldn't get it out do you feel like writing has led to your successes does it play a role in understanding spine care and spine pain absolutely one of the things that I find is that through writing that is the way which I bring my ideas to fruition I bring what's kind of floating around in the back of my head to the front and allows me to really communicate to myself as well as to others what's on my mind and what what I've learned and how I can put it all together so I find writing to be very very helpful in that regard and my writing has been helpful in my career because when your name is out there and your work is out there and if fortunately people find your work to be of high quality and beneficial that brings you recognition that can be brought through personal communication but having publications out there are really helpful in that regard well I do have a patient scheduled in just a little bit but I would be remiss if I didn't get through some of the other listener questions that were submitted Jerome asks on Facebook does the audible release play a role in outcomes? I'm assuming he's talking about the cavitation with spinal manipulation that's a good question so manipulation is a very useful tool it's not the only tool and I encourage chiropractors to avoid attaching their identity to that one procedure rather than attach their identity to helping patients overcome problems being a problem solver so I'll start with that the literature is pretty clear there's been a number of studies that the audible release itself is not a necessary component in order to bring about benefit of manipulation my experience is that it's highly individual that if you take if you look at a population of patients and you treat one population with a high velocity technique that brings about an audible release and another population with a low velocity technique that does not bring about an audible release pretty much both groups will do just as well both benefit equally but there are individuals within each group that may benefit from a cavitation technique whereas there are other individuals that may benefit more from a non-cavitation technique so I think it's essential for chiropractors to be good at both be good at cavitation techniques be good at low velocity non-cavitation techniques Dr. Dean Smith asks and I think this is very helpful for reason graduates with what you know now how might you approach chiropractic school and practice differently as a new graduate compared to the way you originally did oh wow that's a great question how would I approach well I would definitely be more focused I would definitely I would have my again my self identity as I just mentioned self identity placed firmly in the area of I'm my purpose is to help patients overcome spine related disorders rather than place my identity on a certain set of procedures that frees you that's a very freeing process because if you're just here to help if you see your identity and your role as just helping people then whatever you do to help people is what you do and if somebody disparages manipulation that doesn't reflect on you personally you don't have to take that personally because manipulation is simply a tool that you use to fulfill your real mission and that is helping people so I think I would that would be my the main thing I would do differently is really focus my my identity and my approach on on helping patients rather than on who I am and what I do lastly I'd like to ask for those who may be considering chiropractic school what do you feel is the most important thing students can do when choosing to go into chiropractic and then choosing a chiropractic school well I think number one being realistic and recognizing that the chiropractic profession is in the is in a maturation process as a profession we're in the process of we're in our adolescence and we're trying to find ourselves if you remember the painful period of adolescence you remember you were trying to find yourself and you were conflicted and it was a very turbulent period and perfect was that it was an awful time awful but a time of opportunity because you came out of that with a crystal clear identity of who you are and so chiropractic is currently in its adolescence and we're I think we're going to come out of our adolescence having a clear vision of who and what we are what we have to offer but right now we're in our adolescence and I think we need to be realistic about that and it really worked toward maturing and becoming an adult profession and that's not I don't mean that disparaging by the way that we're immature babies as a profession that's just the natural evolution of professions. Well Dr. Murphy thank you so much where can students learn more about you and about the primary spine practitioner process there will be a web presence with the University of Pittsburgh course to learn more about me and about primary spine care in general I would encourage them to visit the website of spine care partners which is a company that I'm a part of if you just Google spine care partners and the primary spine practitioner network there'll be information about me and about primary spine care there and I'd be remiss but if I didn't say my books have a lot of good information about both as well I highly recommend the books I'll include links in the show notes for students to find those directly on Amazon as well as links to a lot of the other things that we have discussed today as well as a collection of papers that discuss primary spine care from a number of different viewpoints well thank you so much I have so many other questions I would love to get to so maybe we can find a time in the future to continue this conversation that'd be great thanks don't forget to get your unlimited data backup for your Mac or PC that charges $5 a month by going to exploringchiropractic.com slash backblaze hey I greatly appreciate an iTunes review please go to Exploring Chiropractic on iTunes and leave a review with your comments and thoughts about the show you can also contact me at exploringchiropractic.com on Facebook, Twitter and Instagram at Exploring Chiro