Patient-Centered Practice
How can chiropractors and chiropractic students help the profession evolve so that it more fully reflects our noblest aspirations? For students immersed in mastering large quantities of technical information and field practitioners focused on day-to-day matters of patient care and practice management, such questions are usually crowded out by the press of immediate responsibilities. In the long run, however, the answers to these questions are crucial.
To survive for many generations, a healing art must be grounded in a system of enduring principles. Lacking that structure, the centrifugal force of new developments exerts too strong a destabilizing pull, eventually leading to loss of fundamental identity. To remain a distinct profession well into the future, chiropractors must hold fast to certain core principles. These principles include concepts shared with other natural healing arts along with unique chiropractic contributions to the overall body of healing arts principles and practice.
In addition to upholding the vital concepts of chiropractic and natural healing, individual chiropractors can influence the future path of the profession by doing the following:
• Distinguishing clearly among the proven, the probable, and the speculative
• Taking care to diagnose and prognose in ways that empower patients
• Minimizing patient dependency
• Serving people who cannot afford chiropractic services
• Making healthy lifestyle choices and thereby serving as a good example to others
• Modeling qualities of tolerance and openmindedness
• Learning about other healing traditions and interacting constructively with their practitioners
Although externally driven events will always exert an influence, the destiny of chiropractic is primarily in our own hands.
FOUNDATIONAL PRINCIPLES
Chiropractic could not have survived for a century without largely adhering to the tenets of natural healing enunciated by Daniel David Palmer and other chiropractic pioneers. These precepts include the following principles drawn from the common domain shared by all natural healing arts:
Natural Healing Principles1
1. Human beings possess an innate healing potential, an inner wisdom of the body.
2. Maximally accessing this healing system is the goal of the healing arts.
3. Addressing the cause of an illness should, in most cases, take precedence over suppressing its surface manifestations.
5. Natural, nonpharmaceutical measures, including chiropractic spinal adjustments, should, in most cases, be an approach of first resort, not last.
6. A balanced, natural diet is crucial to good health.
7. Regular exercise is essential to proper bodily function.
Endorsed and elucidated by chiropractors for more than a century, these precepts are recognizable today as the foundation of the emerging holistic health or wellness paradigm.
Core Chiropractic Principles1
The following constructs comprise the theoretical underpinning of chiropractic:
1. Structure and function exist in intimate relation with one another.
2. Structural distortions can cause functional abnormalities.
3. The vertebral subluxation is a significant form of structural distortion and dysfunction and leads to a variety of functional abnormalities.
4. The nervous system occupies a preeminent role in restoring and maintaining proper bodily function.
5. The subluxation influences bodily function primarily through neurologic means.
6. The chiropractic adjustment is a specific and definitive method for correcting the vertebral subluxation.
Although the precise definition of the subluxation has changed over the years (see Chapter 7), emphasis on the interplay among subluxation, the nervous system, and human health has been at the core of chiropractic concerns since the birth of the profession, and it remains so today.
TOUCHSTONES FOR FUTURE ADVANCEMENT
For individual chiropractors and the profession as a whole to rise to the challenges we face, we must draw upon the best of our history, looking inward with rigorous self-analysis and then acting based on a sense of higher purpose. To accomplish this task, the following points should be considered:
1. Distinguish clearly among the proven, the probable, and the speculative. Some of the most justifiable criticism of chiropractic has been in reaction to the tendency of some chiropractors to globalize,2 making broad overarching claims on the basis of limited, though powerful, anecdotal evidence. Anecdotal information and case studies can be of genuine value in formulating the basis for further research; these elements should not be mistaken for scientific proof. Chiropractic’s integrity and credibility, as well as its compliance with regulatory agencies, depend on its practitioners consistently making this distinction. To do so, we must stay well acquainted with current research. Keating (Internet communication, 1996) has noted that all health professions use unproven methods (the majority of conventional medicine’s methods appear to be unproven) 3,4 but that it is never acceptable to make inaccurate claims about these methods and techniques.
2. Recognize the power of your diagnoses and prognoses. Doctors have the power to dramatically shape patients’ views of their own health. Chiropractors have a responsibility to tell the truth, as well as a further responsibility to frame that truth in the manner most empowering to the patient. A patient once came to me with neck and shoulder pain, relating that she had been told by her previous chiropractor that on a scale of one to ten (ten being the ideal) the chiropractor rated her overall health at three. In my judgment, this was a healthy, vibrant young woman who happened to have some musculoskeletal pain. However, time and effort was needed to convince her that she was basically well. In our role as healing arts professionals, we need to be careful not to unthinkingly alter our patients’ self-perception for the worse. We can convey to them that they are fundamentally ill people or that they are healthy people who currently have certain symptoms or imbalances. There is a world of difference. Conveying confidence in patients’ strength and healing potential is essential. Even with severely ill patients, tempering honest evaluation with hope is important.
3. Minimize patient dependency. Most chiropractic cases require multiple visits. However, as J.F. McAndrews noted earlier in this text (Chapter 28), “depending on which chiropractor a patient sees, the recommended course of care for the same condition may vary drastically, from several visits with one doctor to several dozen—sometimes hundreds—with another. Such variations appear in all regions, among graduates of all chiropractic colleges, and in urban, suburban, and rural settings.” Driven in some cases by perceived or real financial pressures and in other cases by a sincere belief that most or all patients require long-term, visit-intensive chiropractic care, chiropractors may discourage patient independence by scheduling more visits and performing more procedures than truly required for patients’ well being.
Because some of these subliminal motivations reside in everyone, a conscious effort must be made to recommend only the treatment that is truly needed. Greater patient self-sufficiency can be encouraged through active prevention, teaching exercises and other self-care methods, and decreasing frequency of treatment as soon as appropriate. Kingsbury5 notes that in the early days of the profession, doctors spoke with pride of how few visits were required to resolve a patient’s condition and how long a patient was able to go without needing another adjustment. Such a mindset reflects a deep connection to the true purpose of chiropractic and is emblematic of a patient centered practice. This approach contrasts sharply with providers who include in their definition of success maximizing the number of visits per case.
4. Promote a healing partnership and patient-centered approach. Doctor-patient relations are imbued with certain inherent inequalities. These differences include the physician’s social status and specialized knowledge, as well as the patient’s sense of insecurity resulting from his or her illness and disability. 6 Physicians should offer patients opportunities for empowerment so that the inequality created by their specialized knowledge is not generalized to all aspects of their relations with patients. Gordon argues persuasively for a healing partnership7 in which the usual hierarchical model is transformed into a more egalitarian one whereby patients assume a significantly more active, responsible role. Gatterman makes a similar case in the context of chiropractic education and health care delivery. 8 Both Gordon and Gatterman call for a pattern of doctor-patient interaction that moves beyond the “men in white coats” hierarchical model that has currently become a cliché. These authors embrace a mutually respectful relationship that calls on patients to relinquish powerlessness and doctors to surrender some of their power.
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