"The traditional model of medicine simply does not regard communication skills as central to the practice of medicine."1
Might such an allegation also apply to the chiropractic physician? Bluntly put, is there a separate and specific course devoted to doctor/patient communication in any of our chiropractic colleges? To the best of this writer's knowledge, none offer a course in which our future practitioners are taught how to communicate with patients and with one another.While there may well be chiropractic colleges claiming to include such material in one of their other courses, it is highly improbable that a course exclusively devoted to doctor/patient communication can be explicitly found in their catalogues.
Recognizing this deficiency and responding to this felt need, most medical schools in the US require formal communication training.2 Many medical schools in Canada, Great Britain, Australia and elsewhere are headed in the same direction. Can the chiropractic profession make the same claim?
I'd like to share with you the essence of a recent conversation I had with a younger member of our profession who has been in practice for the past 10 years. (I shall be represented by the letter A and my colleague by the letter B).
Dr. A: Do you think the average chiropractic physician is a good communicator?
Dr. B: Yes, if they have a successful practice, they must be good communicators.
Dr. A: Where do you think these successful practitioners learned how to communicate?
Dr. B: I guess some of them just have the natural gift, while others have taken management courses and were taught how to communicate with patients.
Dr. A: Do you think any of the people teaching these management courses possess a university degree in communication?
Dr. B: I don't know. I do know that most of them have had, or do have, very large practices. Besides, what good is all that theory? The bottom line is still the number of patients they see each week.
Dr. A: If I understand you correctly, you do not believe that a formal course in professional communication has a meaningful place in a chiropractic college.
Dr. B: Not really. Theory doesn't bring in patients or pay the rent.
This was the gist of our conversation. I came away wondering how many other chiropractors share my young colleague's view. I also wondered why those responsible for chiropractic college curricula have chosen not to offer courses in professional communication. I am not referring to a simplistic view of communication incorporated into some management course, but rather one that is exclusively devoted to professional health communication.
Returning to a previous point, can or should one assume that any chiropractor who sees a thousand patients a week is a good communicator? Stretching our concept of communication to its outer limits, let us do some simple arithmetic and see just how much time such a practitioner can actually spend with each patient. If he practiced six days a week, eight hours a day, never went to the bathroom, and had neither lunch nor a coffee break, how much applied treatment time could he possibly spend communicating with each patient? If you do the math, it comes out to about three minutes with each patient. It sounds very much like an assembly line of backs: in and out.
Does the end justify the means? Should it automatically be taken for granted that the bigger the practice, the better the communicator? Should the terms curing and healing be regarded as synonymous? I emphatically contend that something more should be shared between doctor and patient than solely an adjustment administered in relative silence. Patients might be cured of their symptoms, but not healed emotionally, spiritually, or psychologically. Lest my meaning be misunderstood, it is my contention that, in addition to what doctors do, strict attention should also be paid to what they say. Put another way, it is the successful marriage of words and actions that should constitute the epitome of therapeutic communication.
As we enter the 21st century, our society continues to suffer from a chronic case of "depersonalization." And from all indications it shows little promise of improvement. Along with government, people have been reduced to statistics. Are we in chiropractic guilty of doing the same thing by reducing each patient to a back? How much humanity, caring, and healing can occur in a scant three minutes? Does the fallacy, "What is true of its parts, is true of the whole," apply here? Are we communicating via the subluxation "as if" it were the whole person? By analogy, does the MD whose practice consists entirely of giving shots also commit this fallacy? While rebuttal from both fields will probably argue that what they do is definitely communication, I prefer to think that, whenever possible, therapy should definitely include a verbal component. This, as I have said previously, is the essence of cooperative healing.
One of the most compelling voices I hear from our profession extolling the importance of interpersonal communication is that of Dr. Chester Wilk, a distinguished colleague whose efforts I enthusiastically applaud. I join with him in encouraging our profession to place greater emphasis on the role communication plays in the practice of chiropractic and in the education of our future doctors.
My 25 years of teaching communication and 42 years as a DC have convinced me that the average practitioner has only a superficial knowledge of what the subject of communication actually entails. Let me specifically enumerate several of the subjects subsumed under the rubric of communication and how these aspects of communication are relevant to the practice of chiropractic.
A knowledge of the art of public speaking could prove invaluable to the doctor choosing to provide patients with a regular lecture series, or addressing various community groups.
Decision-making plays a crucial role in deciding what course of treatment a patient should receive, or how one should proceed in the event of a malpractice suit.
Nonverbal communication plays a cardinal role in diagnosis, by carefully observing a patient's silent messages and physical manifestations. Also, while taking a case history, patients often display a number of nonverbal signs that should be factored into arriving at a reliable diagnosis.
Group discussions at all kinds of professional meetings likewise serve as a valuable tool and an effective means of facilitating shared meaning, and thereby arriving at a consensus.
Conflict resolution and problem-solving are equally important when there are interpersonal differences between staff members or professional colleagues.
A knowledge of argumentation enables members of our profession to disagree without being disagreeable.
Persuasion, unlike argumentation, is an excellent instrument to encourage patients to better comprehend the importance of structural integrity and the need for regular chiropractic care.
Being aware of the dynamics of intrapersonal communication endows chiropractic physicians with the ability to better understand themselves and, in the process, communicate more effectively with patients and staff.
Organizational communication provides insight into how groups work and the best way to make them work better.
Neurolinguistics attempts to codify and synthesize research on nonverbal communication with that of other fields of communication, including cybernetics (how the brain processes information), and language studies. This area of inquiry alone could represent an important clue to improved doctor/patient interaction.
Since theory and practice go hand in hand and, in a sense, are symbiotic, neither one does well on its own. Ideas taken together are the stuff from which theories are constructed. These are then translated into practice. Management courses tell you how to build your practice; theory tells you why it works. In both instances, understanding is crucial.
What does all this say about our profession? To what can we attribute the fact that in almost a century we still have not been able to achieve one voice. Say what you will about the AMA, their one voice has enabled them to withstand a great many charges of wrongdoing: needless or careless surgeries; drugs with serious or unexpected side-effects; insurance fraud; and hospital inequities. Perhaps the adage, "United we stand, divided we fall" makes more sense than we choose to realize.
But how is that "one voice" achieved? Must we first be threatened with extinction? With managed care breathing down our necks, have we arrived at the eleventh hour? We can no longer enjoy the luxury of the polarization we have displayed in the past. Although the ICA and ACA have met and tried to resolve their differences, we continue to hear more than one voice. Ironically, the resolution of our differences has little to do with intelligence. It may well be a matter of ego. I am confident that each faction understands what needs to be done. Why then can't they just do it?
While psychologists remind us of the maxim, "A problem well stated is half solved," rhetoricians ask, point blank, "What is the problem?" The polarization within our ranks suggests two cardinal road blocks to arriving at a unified front: (1) having one voice on the question of chiropractic theory and philosophy; (2) our scope of practice. Once a consensus is reached on these issues, we can assume our rightful place in the health care system and move forward.
An amusing anecdote fits in nicely here. Shortly after the Six Day War, Israel government wanted to build a tunnel under a river. To verify the plans submitted by their resident engineers, a New York engineering firm was called in for consultation. When the firm's representative sat down in conference with the Israeli engineers, he asked, "Exactly how do you plan to proceed with this project?" They replied, "We thought we would have some of our people begin digging on one side of the river and another group begin digging at the other side." The American engineer then asked, "But what if they don't meet in the middle?" Without a moment of hesitation, they answered, "Then we will have two tunnels!"
This anecdote illustrates a certain mind-set and a unique way of looking at things. Those who mediate labor disputes acknowledge that advocates on both sides of any issue harbor disparate views. In the controversy plaguing our profession, the discrepancy over philosophy, theory, and scope of practice are paramount issues in dispute. To achieve any kind of resolution or consensus, it is essential that such ingredients as flexibility, open-mindedness, compromise, and solidarity of purpose be liberally exercised by all parties. Unfortunately, the logic and rationality required to implement these ingredients are not always compatible with ego. Indeed, ego can be a very formidable obstacle.
For the sake of discussion, let us attempt a marital analogy. Imagine that the ICA and the ACA are married and are having marital problems, that is, they are not communicating. Each accuses the other of being hardheaded, stubborn, and unreasonable. They agree to see a marriage counselor who talks to each one separately and hears out their particular point of view. He then brings them together and seeks to determine whether there is a mutual desire to save the marriage. Unfortunately, not all marriages are salvageable. After all viable options are placed on the table, each probable avenue of solution is explored. During this process it becomes evident to the marriage counselor that while divorce seems to be the inevitable outcome, neither party can live a meaningful and productive life without the other.
In applying this analogy to chiropractic, a continued state of estrangement between the ICA and the ACA would render neither organization a very high survival value. An even worse scenario would result from an outright divorce or split between the two groups. This is especially true in the light of present day health care reform in the making.
Our legislators have an aversion to hearing from a profession with multiple voices. They prefer a profession with only one voice. This should portend the handwriting on the wall. We are running out of options. Although our profession can probably survive in its present form, its professional standing is seriously disadvantaged.
In the '50s and '60, it was not uncommon for medical and chiropractic doctors to be pitted against one another in debate on radio and television. And because public opinion was then heavily weighted in favor of the medical profession, the MDs clearly had a rhetorical advantage. Conversely, the members of our profession who were called upon to represent us patently lacked the necessary training in communication and argumentation to offset that medical edge. Since those bygone days however, because of the intensive and unrelenting public relations exerted by our profession, that medical edge has become significantly dulled. In consequence, more and more young men and women possessing undergraduate and graduate degrees have discovered chiropractic to be a very attractive career alternative. This has endowed us with a new breed of graduates possessing a far more impressive academic persona.
Let us now return to the title of this article: "Why Aren't We Communicating?" I hope I have persuaded readers to acknowledge the pressing need for our colleges to offer separate and distinct courses in professional communication taught by people with degrees in communication. The subject should not be treated as something that any successful practitioner can teach. Just because a person is an excellent golfer, it does not mean that he can teach others: playing is one thing; teaching is another.
In closing, may I ask my colleagues to please let me know which of our colleges is currently offering a separate course(s) in professional communication. Also send me the number and course description given in the catalogue. I would also appreciate your opinion on the subject raised by this column. Write me at the address given at the end of this piece.
- Korach BM et al. Gaps in doctor-patient communication. Pediatrics 1968;42,855-871.
- Kahn GS et al. The teaching of interpersonal skills in U.S. medical schools. Journal of Medical Education 1979;54,29.
Abne Eisenberg, DC, PhD