Clinical Decision-Making: Enhancing the Art of Chiropractic

By Marc Heller, DC

When your patient presents with a particular complaint, how do you approach them? I have noticed particular errors I have made, and particular approaches that seem to help me get to the deeper answer. This article is about the art of chiropractic - my views on a "best practices" approach.

First, the patient has the right to more than one problem. The patient may have a sacroiliac dysfunction and an irritated sciatic nerve. He or she may have a sternochondral dysfunction and a gastroesophageal problem, both contributing to chest pain. A magnesium deficiency will keep muscles from relaxing, allowing myofascial pain to persist, no matter how good your manual treatment. Getting focused on the obvious mechanical problem can keep you from identifying other underlying problems.

Second, you can only find what you are familiar with; what you can conceive. If you think every problem is caused by subluxations, you will only look for and find subluxations. If you think every problem is caused by muscle imbalance, that's all you will look for and find. If you are more comfortable with spinal adjusting than extremity adjusting, you'll attract primarily spinal conditions and miss many significant subluxations in the extremity that affect global function. I suggest you expand your toolbox, both in terms of technique and in terms of mindset. Look broadly.

Third, a key skill is "thin-slicing." As human beings/doctors, we are capable of making sense of situations based on the thinnest slice of experience. I'll quote from Malcolm Gladwell's comments about his new book.1 Gladwell says Blink is "a book about rapid cognition, about the kind of thinking that happens in a Blink of an eye. Blink is a book about those two seconds, because I think those instant conclusions that we reach are really powerful and really important and, occasionally, really good." I think as chiropractors, we are constantly using these principles of quick decision-making, for better or worse. Our work, rapidly assessing a patient and determining a treatment, requires us to make sense of a huge amount of information quickly. Gladwell's book is a broad view of this topic.

Fourth, can you switch gears quickly? Can you let go of your preconceptions and take a new look at your patient? You know which of your patients usually respond to one or two adjustments, and which take a few more. When someone who is usually a quick responder is not changing, you need to re-examine that patient and redo the history. This does not have to be extensive; just really listen to the patient describing the problem. Sometimes, some little phrase will pop out, telling you what to look for.

I find that when I let go of my concept of what the patient has wrong, my re-exam may reveal a completely different set of findings.

I recognize my chiropractic exam is primarily soft data. I mean that palpation, muscle testing, and leg checks, even range of motion are not completely reproducible types of diagnostic tests. MRI and X-ray analysis involves looking at shadows, and attempting to interpret them and correlate them with the clinical picture. The results of my physical exam findings can be influenced strongly by my intent. What am I looking for? If I know what I am going to find in advance, I will most likely find it. If I keep an open mind and stay open to the mystery of the human body, I am more likely to get useful information. Some of my academic colleagues would tell me to not use palpation or muscle testing, because they do not pass the test of objective documentation. I would say this: To be an excellent clinician I need to gather enormous data, and then thin-slice it by filtering it through my pattern recognition system (my brain). I make a conclusion, and then I perform a short clinical trial: the adjustment, the recommended exercise, the specific soft-tissue work. If my diagnosis is correct, I usually will see a change in my patient's condition. If not, I go back and start over.

Craig Liebenson makes a similar point in his recent Dynamic Chiropractic article, "Are You Turned Off by Evidence-Based Care?"2 He states, "Evidence-based care guidelines inform our practices with general principles of care, but they do not guide our clinical decision-making on an individual basis. As a general rule, treatments that result in within-session improvement should be repeated, and those that don't, discarded."

A case of mine comes to mind. It involved a woman with a chronic right hip problem, who probably will need a hip replacement sometime in the next few years. She strained her left hip, and I was able to help her. She then started having pain in her left ischium whenever she sat down. I had been focused on her hips, and had been having previous success with her using Graston Technique. I tried Graston to the sacrotuberous first, finding tenderness around her left ischial tuberosity. She did not respond, and I finally had an "Aha!" moment. I re-examined her, figured out she had sciatica with involvement of the L5-S1 junction, which I had somehow previously missed. Within two treatments focused on the sciatica and lumbar problem, she was 90 percent better.

When are you done with an office visit? How does the patient feel immediately after an adjustment? I expect my patient should leave my office feeling substantially better. If they don't feel better, if they don't feel "right," it usually means I missed something, or some part of their system has not been able to respond to the changes appropriately. I tell my patients to let me know if something doesn't feel right after the adjustment. I can usually find the missing piece, correct it in 30-90 seconds, and they go out feeling complete. I find I have far fewer treatment reactions if I follow this simple protocol. I find I do better with this attitude than having a rigid "my indicators say that I am done" attitude.

I hope my thoughts on the subtle aspects of optimal clinical care are helpful. Most of us are somewhat isolated as doctors, working in our practices. Ongoing continuing education, ongoing study groups, and continued reading and thinking can make us better doctors and keep the flame alive. I learn something new every day I go to the office. I hope you can continue to bring this excitement and fascination with the mysteries of human health to your practice.


  1. Gladwell M, commenting on Blink: The Power of Thinking Without Thinking.
  2. Liebenson C. Are you turned off by evidence-based care? Dynamic Chiropractic, Feb. 12, 2005:

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