No Change or Worse: What Should You Do?
By K. Jeffrey Miller, DC, MBA
It does not take long in chiropractic to experience or participate in a "chiropractic miracle." You know what I'm talking about. A patient is carried into the office and walks out, or a patient who consulted medical doctor after medical doctor finally consults a chiropractor and obtains great results. These are wonderful events. They are great experiences for the patient and doctor. They also help convince many who need help to try chiropractic.
Unfortunately, the opposite can also occur. Patients sometimes see no improvement in their health or may actually get worse. It is a fact of life. If you are saying to yourself, "That never occurs in my practice," your patients should run. A simple check of how often you send patients' records to other doctors and a small satisfaction survey of patients who have discontinued your care will check that ego quickly.
While the miracles outweigh the failures by a wide margin, we should still make efforts to discover why a patient does not improve or becomes worse. Occasionally, we simply could not have prevented their declining health, while other times, we could have. Ideally, we discover whether we can help the patient prior to them giving up on the chiropractor and/or chiropractic care.
Sometimes, it is the patient's own actions or lack of action that results in failed treatment. Patients are notorious for not following doctors' advice. They miss appointments, won't do their exercises, don't wear their orthotics or take their vitamins, won't follow light-duty orders and don't curtail activities that perpetuate their problems. (This is just the short list.) Many of these patients make excuses and complain about their lack of progress, believing it isn't their fault - it is the doctor's fault.
This is irritating and insulting. It is hard to help someone who won't help themselves. You can be bothered by this to the point that you adopt the reverse of the patient's logic, believing the patient is always at fault for poor results and that you are blameless.
It is hard to change patient behavior, but we can change our own. We must learn to recognize patients' lack of follow-through and call them on it. We must also learn to recognize our own shortcomings and address them, hopefully before the patient leaves dissatisfied or angry. To do this, we must question our own work, rethink the examination process, reconsider the diagnosis and reassess our treatments and skills. Should more diagnostic procedures be performed? Perhaps you have not taken X-rays, or need to take more. Maybe an MR or lab tests such as chemistries would help. Additional diagnostic procedures may help identify information not considered initially. This may update the diagnosis and the course of treatment. The best treatment in the world is not effective when the diagnosis is inaccurate.
With additional diagnostic information, you may discover that the patient is not truly a chiropractic patient. In that case, a frank referral is necessary. Some may argue that everyone is a chiropractic patient. Philosophically, it would seem that we have an unlimited scope of practice, but by state statutes, we have a limited scope. We also have an obligation to patients to put our philosophies aside for their benefit and well-being. In some cases, a second opinion from a health care provider in another field or another chiropractor could help.
Yes, I said another chiropractor. It is shameful for a patient to give up on chiropractic as a whole because one chiropractor is too stubborn to refer to another chiropractor. It is equally shameful for the chiropractor asked for a second opinion by another chiropractor to badmouth the referring chiropractor and/or attempt to steal the patient. I know I'm striking a nerve and pushing the limits on some comfort zones by talking about chiropractor-to-chiropractor referrals, but it is necessary. The patients who don't improve or get worse in a practice are a small minority. A few referrals a year will not kill a practice.
Maybe the technique you selected for the patient isn't working or your adjusting skills need refinement. All techniques work and all have shortcomings. Try something different. If you are a purist using a single technique, refer to someone who uses a different technique. With choices of technique comes examination of your technique/adjusting skills. I know - ouch! But think about this. If you ask a chiropractor who is the best adjustor in their town, they always say, "I am." Nobody ever names another doctor or says, "I'm third." In actuality, someone is second, third, fourth, etc. Perhaps the methods of care you use to support the adjustment could be utilized more efficiently. Maybe you are using too much passive therapy and shouldconsider more active rehab. Maybe you are not addressing the patient's nutritional needs. Perhaps you aren't using any additional methods of care and should be.
The economy is down and with it, patient numbers are down. The chain continues with a reduction in seminar attendance in the profession. When practice is down, no one seems to want to participate in more than the required amount of continuing education. This is another shame because when practice is slower, it is the perfect time to continue your education. You may not have as much money to invest, but you do have time to invest. Study a new technique. Attend a course on your established technique. Maybe you should learn more about orthotics or add rehabilitation procedures to your practice. Perhaps you should take a CCSP course on implementing cold laser.
The Japanese use a method of continuous improvement referred to as kaizen. The process involves self-assessment and improvement. It is a good idea for every endeavor and is especially important in chiropractic and health care in general. We owe it to the patients, our profession and ourselves. Give credit where credit is due and give blame where blame is due. If the patient is at fault, call them on it. If a patient isn't compliant, tell them what Dr. Brian Jensen recommends, "If you don't follow the treatment plan, you give up the right to complain about the results." If the patient is compliant, but not showing the expected signs of improvement, then re-examine your methods and skills.
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