When I started at University of Bridgeport College of Chiropractic 19 years ago, I did locum tenens (coverage) during university vacations. These experiences were, to say the least, interesting.In some ways they were terrifying experiences because often the documentation was so utterly horrid or totally illegible that I had little idea what was going on with the patients beyond their names - and sometimes I couldn't even make those out.
I've heard from some chiropractic physicians that the whole documentation "thingy" was never (nor should it have ever been) a part of chiropractic care. They've implied that documentation is not for the patient's benefit and is a hospital-only practice. However, when doing locum tenens one sees the value. Sometimes the level of documentation is determined by what is called the "dead doctor rule." The documentation should be of a quality and quantity such that another doctor assuming the responsibility of patient care for a recently deceased doctor would know all the pertinent clinical information just by looking in the patient's chart. To the doctor doing locum tenens, the owner of the practice is effectively dead for the duration of one's temporary employment in that practice.
However, as I noted, some doctors I have covered for practiced the art of minimal documentation. For example, there was one doctor who only wrote "CDL" in each chart note. The staff informed me that this meant he had adjusted the cervical, dorsal and lumbar spine. The champions of minimal documentation were, of course, the doctors who wrote absolutely nothing whatsoever for their daily chart notes.
In an effort to prevent embarrassing the doctor I was covering for, I got into the habit of saying to patients, "Save me from reading doc's hieroglyphics and tell me what they've been doing." The answers were shocking, even more shocking than the lack of proper documentation. The most common response I heard was, "Doc cracks me, but then the girls put therapy on me and I feel better." Thus, many patients didn't see, or shall I say, didn't feel the value of the chiropractic adjustment. In fact, in many of these offices the patients would decline having me treat them at all and would just go to the "girls" for "therapy." (You might think this is because the patients didn't want a different doctor to adjust them, but the staff usually told me that the patients didn't want the adjustment ever; they just couldn't get away with not having it with the doctor who owned the practice.)
There are certainly cases managed by chiropractors in which the treatment of choice is not spinal manipulation.1-2 However, if manipulation is appropriate to the treatment plan, then the onus is on the doctor to clearly communicate the need and the value of manipulation to the patient. This is part of informed consent - having a conversation about the proposed treatment, its material risks and benefits, and the alternative treatments (including lack of treatment) and their material risks and benefits.
Likewise, if manipulation is appropriate to the treatment plan, then the onus is on the doctor to provide an effective chiropractic manipulation. Maybe it's my ego, but I have always felt that if the patient hasn't experienced a quantum of improvement at my hands (chiro+ praktikos, done by hand), there is something wrong with what I am doing. Axen, et al., found that when a patient experiences some improvement as a result of the first visit, this predicts a positive prognosis for the patient.3 Thus, the patient who feels a value to our treatment will likely respond positively and recover.
A friend told me a story about something that happened when he was in chiropractic college. He met a man who, upon finding out that my friend was a chiropractic student, told him he'd been to a lot of chiropractors for his low back pain, but none had helped him - that is, until he found his current chiropractor. According to the man, his current chiropractor was very effective; in fact, he said he'd go daily and multiple times daily if he could afford it.
Some might think this doctor is really helping the patient. However, my friend asked the man how his low back was. The man said it had not changed and still hurt. My friend found out later that this doctor had a staff member who timed how long the doctor was with patients and knocked on the door if the doctor was spending more than 45 seconds with the patient! Clearly, this doctor had successfully gotten this patient to find value in his care, but he did it by changing what the patient was looking for.
Shouldn't our value be providing, at minimum, what the patient is looking for, in this case relief of back pain? I understand the argument that we have more to offer then just pain relief, but what is our value if we can't even do that and instead replace the patient's need, pain relief, with doctor dependence?
- Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord, 2007;8:75.
- Murphy DR, Hurwitz EL, Nelson CF. A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature. Chiropr Osteopat, 2008;16:7.
- Axen I, Rosenbaum A, Robech R, Wren T, Leboeuf-Yde C. Can patient reactions to the first chiropractic treatment predict early favorable treatment outcome in persistent low back pain? J Manipulative Physiol Ther, 2002 Sep;25(7):450-4.
Click here for previous articles by Stephen M. Perle, DC, MS.