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Dynamic Chiropractic – March 26, 2010, Vol. 28, Issue 07

Coaching Patients Toward a Healthier Future

By Shelley Simon, RN, DC, MPH, EdD

Does your vision for the ideal practice include a schedule full of loyal and appreciative patients who are keenly engaged in their own journey toward health? Most chiropractors would nod in full agreement with such a vision.

I've heard from countless numbers of doctors some variation of, "I don't want to be just a pain doctor; I want to treat the whole patient." That's understandable. Taking a wellness approach with patients is meaningful and rewarding. It is important to appreciate, however, that pain is what initially brings many new patients to your office door. How you approach these patients at the outset determines much about their clinical outcome as well as your satisfaction in practice.

Patients who come to your practice are almost always seeking relief. Most are experiencing pain that is, to some degree, limiting for them - perhaps they have chronic headaches, neck and shoulder pain, or an aching or injured back. While chiropractors are used to hearing that a patient's primary goal is pain relief, they too often devalue this motivation as being short-sighted, symptom-focused, and merely the tip of the iceberg. No matter how strong your wellness philosophy may be, pain must be understood from the patient's perspective before you set about reframing their problem, motivation, or goals and expectations.

This is not to say that you can't also work toward motivating patients to look beyond their immediate symptoms and make recommendations that will help them imagine a healthier future. You can, right after you show due respect for what brought them to your office, acknowledge that they are in distress, and address their pain as a pressing challenge for them.

Although you know that pain is usually just one symptom of a larger issue, it is rampant in the population. Patients who are suffering benefit from chiropractors who take a deep and considered approach not only to diagnosis and treatment, but also to helping them make sense of their pain. I propose that by employing coaching techniques (i.e., asking the deeper questions and listening with genuine curiosity), your patients will have better outcomes because you'll better understand their perspective and motivation. This, in turn, can lay the foundation for an enduring doctor-patient relationship.

The Complex Nature of Pain

Pain does not exist in a vacuum. It is a complex, multifaceted experience that is present for patients in relation to their life at both a physical and emotional level. How individuals make meaning of pain, how they deal with it or ignore it, whether they medicate or meditate, and how they generally cope is often a dynamic and highly individualized process. Sometimes patients manage pain well and feel motivated to do what needs to be done to remedy the problem. Other times they may just want to give in to their own suffering, having come to the conclusion that treatment and lifestyles changes are both futile.

To support patients in staying engaged with their (and your) efforts to improve function and feel better, it's essential to understand where they've been, where they are, and where they want to be in terms of their health. What's in it for the patient to continue to work toward feeling better? Why should they invest the time and money in a course of care that, at least in their mind initially, may or may not work in either the short or long term? One might think that being free of pain would be enough of a carrot to motivate anyone to actively participate in their own care. But patients - especially those who have been dealing with chronic pain over a long period of time - may be weary of the whole process.

Adopting a coaching approach with patients accomplishes a number of things. It helps ferret out underlying issues that might be contributing to a patient's pain, such as stress, unhealthy lifestyle choices, or an environment at home or at work that exacerbates their problem. It gets the patient talking, which can help them take ownership in doing their part to improve their health. And it demonstrates caring, empathy, and concern on your part. Using coaching techniques with patients is an engaging process that helps build a solid doctor-patient relationship. Investing the time to ask open-ended questions is something that many health care providers simply do not do. When you engage with patients at this level, you can expect a return on your investment of time in the form of patients who experience good outcomes and become your loyal advocates.

A Six-Step Coaching Formula

Here is a six-step coaching format that will help you better assess a patient's condition, as well as their motivation and readiness to take action. Probing at this level will also help the patient have a full appreciation for their situation and be prepared for the course of care that lies ahead.

1. Why now? What was the tipping point that brought the patient to your office today, as opposed to last week or last year? What did they experience or tell themselves, or what did someone else tell them ("Honey, you're walking like you're 102" or "I'm sick of listening to you complain") that made them pick up the phone and make an appointment. Knowing the answer to the "why now" question will help you better appreciate the patient's sense of urgency, which may influence how ready they are to take action steps toward feeling better.

2. What is the depth of the problem? The degree of pain, extent of suffering, and the limitations the patient is experiencing are helpful to explore not only to aid you in making an accurate diagnosis and developing a treatment plan, but also to support the patient in acknowledging the magnitude of the challenge they are facing. Someone who has been struggling with low back pain for five years may have actually lost sight of just how much their condition is limiting them, until they're asked to describe their level of pain and how it's impacting them on a daily basis. A patient might initially say, "I can't stand this pain anymore" when what they really mean is, "I can't stand how being in pain is ruining my life."

3. What is the cost of the problem? When patients hear this question they might first respond by describing financial cost, that of treatment and perhaps lost workdays. But that's not the kind of "cost" you're trying to get at with this query. Asking about cost is actually an attempt to help the patient understand at a deeper level the price they are paying for the status quo. This might include depression secondary to pain, the inability to enjoy activities, relationship stress due to physical limitations or moodiness, poor job performance, loss of self-esteem, a decline in quality of life, or some combination of these. Once the patient can articulate the cost of the pain, you can ask about the cost of doing nothing. What does the patient think will happen if nothing changes? What is their likely trajectory?

4. What is the preferred future? Guiding a patient to envision a better future is easier than you might imagine. Simple questions like, "What would you do this weekend if you weren't in pain?" and "How would you manage your life differently if you weren't worried about when the next headache might strike?" can elicit emotionally powerful responses. Allow the patient time to come up with either one very clear image for their preferred future, or to explore a few variations on the theme. It's important to stay focused on the patient's story at this point. Honor their story and file it away for future use when you might need to remind the patient of their goal to keep them motivated. For example, you might say, "I remember you saying at one of your earlier visits that you'd like to be able to hike again. Is that still the vision you have for yourself?" Simple, to the point, and powerful because you're telling the patient their own story.

5. How ready are you to feel better? Most patients will respond to this inquiry by saying they're absolutely ready to feel better, right now, this minute, today, or by tomorrow at the latest. This opens the door to have the conversation about the fact that, in most cases, a treatment plan is a process. Here you can discuss expectations and challenges that may arise over the course of care, and how the patient will overcome obstacles they will likely encounter on the way to feeling better (reaching a perceived plateau or not having time to do home exercises, for example). Part of what you are doing is laying groundwork for the patient to embrace the idea that the path toward feeling better may not be linear. Reassure the patient that, although their results might not be immediate, you are confident that they will indeed experience results because you've treated many patients with problems like theirs and seen them return to activities they thought they might never be able to participate in again. In other words, let the patient know they're not alone with their problems, concerns, and desired outcomes.

6. What's your current level of commitment? Just as most patients will say they're ready to feel better "now," they will also express a high degree of commitment to doing whatever it takes to have less pain. But, anyone who has ever started a diet on a Monday morning knows that then the going gets tough, even the firmest resolve can fly right out the window. Ask the patient about times when they've been successful with a change effort (developing or breaking a habit, for example) and how they kept their commitment level high as they worked toward success. Acknowledge with the patient that (especially if they are in for a fairly rigorous course of active and passive care) that their commitment level may ebb and flow, that it's natural for that to be the case, and reassure them that you'll do what you can to help them stay engaged and motivated to achieve their health goals.

The Power of True Healing

There is more to being a healer than having good diagnostic and technical skills. True healing involves demonstrating empathy and compassion for others. When you invest time in your patients by using this coaching process, you are conveying that you understand that your patient is in pain and that you have a genuine interest in helping them feel better. Treating pain day after day may not be your vision of the perfect practice. But relief is what many people need, and you are in position to help those who are genuinely suffering. When you work with patients to help them feel better and have less pain, you gain credibility and increase the likelihood that they will return to you for wellness care for years to come.

Click here for previous articles by Shelley Simon, RN, DC, MPH, EdD.

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