In a recent column [June 17, 2012], I discussed history questions aimed at drawing information from patients who are poor historians.
The responses to the article coincided with ads I began seeing in the back of a state association newsletter by doctors offering fill-in work for other chiropractors. The combination of the responses to my article, the ads and personal experience sparked another 20 questions.
The ads offered facts about the fill-in doctor's technique proficiencies, the availability of malpractice insurance, and assured potential clients of smooth transitions into and out of the practice. These are important factors for a doctor to consider in hiring another doctor to cover their office. The doctor is looking for someone who can practice as close to their methods as possible. This keeps the patients happy and the business up and running in the doctor's absence.
The Hiring Doctor's Concerns
Malpractice coverage is of particular importance. The hiring doctor worries about quality of care and the substitute doctor's abilities, especially if the substitute is unknown to the hiring doctor. And the concerns are not limited to adjusting abilities. The substitute's abilities to record a patient's history, perform a good examination, take and read X-rays, diagnose, write a treatment plan and give a report of findings are also important.
It is a tough decision for a doctor to hire a fill-in doctor. It always appears to be a choice between the lesser of two evils: Should the doctor close the practice for period of time, potentially upsetting patients and losing income, or take a risk with a substitute? Hopefully, the doctor chooses the substitute. Chiropractic is safe and with the parity among our colleges these days, everyone is well-trained. Most patients are satisfied and the business operates until the owner's return. This is an especially logical decision if the hiring doctor's absence is due to a long-term illness.
For extra assurance, the hiring doctor could institute a rule regarding patient care in their absence. The recommended policy would be to not persist with treatment if the patient expresses concerns about being treated by a fill-in doctor. Don't talk the patient into care. This rule will go far toward patient satisfaction and safety. It just makes sense.
The Fill-in Doctor's Concerns
The unusual aspect of this topic, to me, rests in the vantage point from which the topic is almost always discussed: the hiring doctor's point of view – their concerns about patient care, malpractice and income. What about the fill-in doctor's concerns? What if the doctor who owns the practice has poor records, equipment that is in poor condition, uses obscure techniques and/or has inadequate malpractice coverage? While everyone is well-trained, some make minimal effort. What if the owner and their staff are ineffective at filing insurance and obtaining reimbursement? Will the fill-in doctor be paid?
What if a young doctor filling-in while trying to develop their own practice is sued because of the practice owner's treatment? The fill-in's career could start with several marks against them. What if a retired doctor looking for something to do or a little extra retirement money fills in and is sued because of the practice owner's treatment? A stellar career may conclude with a black mark.
20 Questions to Ask Patients When Filling in for the Doctor
Regardless of the concerns, whether a patient, hiring doctor or fill-in doctor, there are ways to improve everyone's sense of assurance. An additional 20 questions are offered here to that effect. The 20 questions are designed for the fill-in doctor to ask to patients during their encounters.
You might wonder, can history questions alone really be that effective in providing safe quality care in times of coverage? I believe they can. McGuirk and colleagues, studying routine imaging of patients with acute low back pain, showed that from history alone, using a red flag checklist, no serious conditions were missed in over 400 test subjects.1 There is definitely a reason why history has always been described as having the ability to provide 80-90 percent of the information necessary for many diagnoses.
These questions will not apply to every patient. For example, a 14-year-old does not have a high probability of having had vascular, spinal or joint replacement surgery. The probability of having heart disease or an occupation would also be rare at 14. There will be times none of the questions is applicable. For example, the patient's records may be available, up to date and clear. The aim for the following 20 questions is good patient care that obviously is of benefit to all parties.
- Have you had previous vascular, spinal or joint replacement surgery? Scars from these procedures are often less than obvious especially in the practice where gowning is not performed for routine visits. Surgeries such as enarterectomies, aneurysm repair, spinal fusions and hip replacements can all affect the type of treatment that can be rendered.
- Have you had any form of cancer? Especially bowel, breast, prostate, lung, thyroid or kidney cancer? The list here includes some of the most common cancers known to metastasize to the spine.2
- Have you had any significant traumas? (previous / current) Previous dislocations, fractures etc., should be known. Joint instability and degeneration can be lasting consequences of such trauma.
- Are you diabetic or suffering from heart, lung or kidney disease? Diabetes affects healing time. Cardiovascular health is an issue in aneurysms, stroke, etc. Lung disease can cause spinal pain. Kidney disease can cause spinal pain and is related to blood pressure regulation.
- Have you ever been admitted to a hospital for an extended period of time? This is a general question aimed at identifying any severe / chronic conditions that might have long-lasting effects.
- When was your last visit to a doctor, other than in this office? What was the visit for? This question often helps identify concurrent conditions and treatment. It can also identify treatment the patient may be receiving for the condition they are being seen for in your office.
- How long have you been a chiropractic patient? Asking this can help determine if the patient have had successful chiropractic care in the past and is comfortable with chiropractic care. It can also identify a patient who is nervous about receiving chiropractic care.
- Has any of your family members passed away before the age of 50? Accidental death must be excluded for this question. The intent is to identify serious disease that may be hereditary.3
- What do you currently do for a living? Information about mental and physical work-related stress is obtained with this question. Occupational duties can influence the mechanism of injury and recovery rates.
- What type of work have you done in the past? Identifying previous occupations can be helpful for the same reasons as question #9, and for collecting information regarding wear and tear from patients who have retired.
- Have you had any recent infections? Many forms of infections can cause musculoskeletal pain, whether they are located in musculoskeletal tissues or not.
- Are you experiencing any current bladder or bowel problems? This question is always stressed for back pain patients to rule out ominous conditions such as cauda equine syndrome.3 (To me, this is like the stroke issue in chiropractic; important but overemphasized. I have seen cauda equina once in 25 years.)
- Where are you currently experiencing symptoms? What symptoms have you had since your last visit?
- Is your visit today for the same condition(s) you were seen for last time?
- Have your symptoms changed in any way since your last visit? (better, worse or about the same)
- Have you developed any questions or concerns since your last visit?
Questions #13-16 are questions a doctor should ask any patient on any routine, of course. They help confirm the patient's present complaint, their progress and response to care, as well as the possibility of exacerbations.
- Does the doctor adjust your entire spine or limit care to specific regions?
- Are there any areas the doctor avoids when adjusting you or areas / ways you prefer not to be adjusted?
Questions #17-18 are to familiarize the doctor further with the care the patient has been receiving and with precautions that have been taken in the past.
- Do any concerns come to mind for you, knowing you are being seen by a different doctor? Is there anything you want me to be aware of?
- Is it OK for me to treat you today?
Questions #19-20 are especially important for the patient who is nervous about seeing a different doctor, especially if they were unaware that there would be a different doctor during their visit. Patients who show up knowing they will be seeing a substitute doctor are usually not nervous. As stated earlier, if there is any question, do not press the matter and reschedule the patient. Question #20 is a good idea in either case for consent to treat.
Again, not every question necessarily needs to be posed to every patient. It would bog down the flow of the practice. And good notes may be available that answer some of your questions without needing to ask them. Additionally, the hiring doctor may have briefed the fill-in doctor or left specific instructions about patients with cases that are less than routine. Many of the questions could be asked while the doctor is performing the pre-adjustment assessment in order to make the process more efficient.
Patients may have a few questions of their own for the fill-in doctor; one might be, "Why are you asking so many questions?" Patients often assume everything is in the file and/or that surely a summit was held between the two doctors regarding their case. The correct answer to the question is, "I am just being thorough."
With the progressive adoption of mandatory electronic records, the questions above will be of lesser consequence. The patient's entire file will be available at the touch of a button. This feature has been available, but many have not utilized it because of affection for travel-card and other record-keeping systems.
The questions here are recommendations based on my experience and observations. They are not sanctioned or set in stone. Every doctor must use their own experience, reasoning and discretion when it comes to clinical procedures.
- McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety, efficacy and cost-effectiveness of evidence-based guidelines for the management of acute lower back pain in primary care. Spine, 2001; 26:2615-2622.
- Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, 3rd Edition. Philadelphia, Lippincott, Williams and Wilkins, 2005.
- Bigos S, Bowyer O, Bren G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. Rockville MD, Agency for Health Care Policy and Research, 1994, AHCPR publication 95-0642.
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