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Dynamic Chiropractic – March 25, 2008, Vol. 26, Issue 07

Diagnosis and Report of Findings, With All Due Deliberation

By John R. Bomar, DC

It has probably happened to you, too: You put your heart and soul into a thorough examination and diagnosis of a patient, outline a reasonable course of treatment and rehabilitation, begin treatment, start to get things going and then the patient disappears just as you are beginning to see improvement.

Most of you can guess why - they became free of conscious pain. Although you know they are far from being fully rehabilitated, they take themselves off the set schedule. It can be frustrating and if one is not careful, such disappointment can lead to cynicism.

Recently, after just such an incident, I reflected on the possible causes of this common development. After some consideration, I had to admit to one possible cause: a patient's lack of confidence in my motives and recommended course of treatment.

Chiropractic's Diminished Standing

Whether we like to admit it or not, our profession has a gaping wound in regard to public trust, both in our work and in ourselves. The inability of chiropractic organizations to mount a comprehensive public education campaign to address these ill perceptions, while largely squandering time and monies on lobbying for legislative redress, has impaired our individual practices and the profession as a whole. In an era in which more and more educated people are drawn to and utilize alternative therapies in health care, we continue to bring up the rear, allowing ourselves to be cast into the singular role of back pain doctor - and a not very well-trusted one at that. While keeping our "pearl of great value" (organic and physiological healing through correcting spinal impairment/impingements) hidden under a basket, we dishonor the nobility of our work and discount its value.

More Time for Deliberation and Recommendations

With this reality in mind, I came to a new appreciation for those who advise a more deliberative approach to initial patient management. Like many of you, I had always been critical of the practice-management types who recommended absolutely no treatment on a patient's first visit. My observation was that these groups also tended to encourage an overly dramatic presentation of findings on the second visit, along with recommendations for a large number of required visits for the patient's ultimate "salvation." Having tried to always follow the simple rule of treating patients as I would want to be treated myself, I disdained this practice as a form of trickery for financial gain. After history and exam, most of my new patients received therapies and treatment, with the first visit running well over an hour.

I now realize this was a disservice to the work and to my patients. In forging ahead, I did not give myself time for adequate deliberation, nor did I give patients a very good perspective on the extent of their problems. Rather than engender patient confidence in my recommendations, my hurried exam, treatment and rescheduling had probably seemed somewhat "off the cuff." This practice also reinforced the patient's misconception that my work related only to back and neck pain and that when their conscious pain was gone, the problem was resolved. As most of us come to know, the most common conditions we treat are actually acute exacerbations of chronic (often hidden) spinal and pelvic impairments. With only a little correction and proper management, the nervous system once again sets up neural-gating mechanisms that block conscious pain. I was inadvertently adding to the "no more pain, no more patient" nature of my practice. Due to our somewhat limited scope of care, we must resist the tendency to be overly casual or even cavalier in patient care.

Relating Somatic to Visceral

In taking some time between assessment and a report of findings, I had the opportunity to more thoroughly evaluate a patient's history of illness. Thus, I began to see correlation between spinal pain and organ dysfunction. I have found Chapman's Neurolymphatic Reflexes to be an excellent reference for identifying areas of reflex dysfunction, and the chart (available online) is particularly useful. As a testament to its worth, Dr. Chapman's book, written in the 1930s, is still being printed. Additionally, using an illustration of the autonomic nervous system and its organic connections has allowed me to explain to a patient the possible benefit of my work to their other health challenges.

What a Patient Wants to Know

Patients are interested in answers to the following main questions:

  • What is causing the problem?
  • How serious is it and what are its complications?
  • Can you help?
  • How long will it take?
  • How much will it cost?

Scheduling the time to fully answer these important questions on a patient's second visit, after honestly considering the answers, will allow you to outline a comprehensive course of treatment that will add great credibility to your recommendations.

Of course, one cannot fully know the extent of needed treatment for any individual. Folks heal and rehabilitate at different levels, and some work much harder than others at their assigned home therapies and exercises. A good friend once told me to "promise less and deliver more" when it came to recommendations on the number of necessary treatments. This seems good advice. I also think that, generally speaking, three series of treatments, each of less frequency than the last, with breaks in between is the best overall strategy for recovery to maximum medical improvement.

There may come a day when we have sufficient standing and trust in the mind of the public that these steps are not necessary for good patient compliance and follow-through. However, today is today, and we must continue our best work in an environment of distrust and skepticism.

In the end, we do no one a very good service if we simply offer palliative treatment for recurring pain syndromes. It is our duty to spread the word individually and collectively that our work has benefit well beyond the spine and pelvis. Taking the time for adequate deliberation and report of findings with an honest recommended treatment plan during the first days of a patient's journey to health seems the proper beginning.

Dr. John Bomar, a 1978 graduate of Palmer College of Chiropractic, practices in Arkadelphia, Ark. He is a past board member of the Arkansas Chiropractic Association and a founding board member of the Arkansas Chiropractic Educational Society. Contact Dr. Bomar with questions and/or comments regarding this article via e-mail: .

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