By: Monte H. Greenawalt, DC, DABCO
Doctor, you are in the people business, and I’m going to help you generate a growing, stable practice.
You want your patients to comply with your treatment plan, and they will—if they understand why you have recommended the plan. Are you ready and willing to do as someone tells you, if you lack the understanding of why you should follow the instruction? Of course, the answer is “no”. Explanations should be stated in clear, understandable way. What prompts you to do as instructed? The very same things that motivate your patients to do as directed.
Most patients are apprehensive—and even reluctant—to visit the doctor. It is of paramount importance to set the stage and make the patient confident that he/she has made an excellent decision to come to you for help. The following steps are helpful in setting the stage to ensure the planned outcome:
A. Telephone. Generally the first contact your patient will have is with your CA answering the telephone. Therefore, place a mirror by the telephone, instruct your CA to look into the mirror and smile. This will put a pleasant, happy, caring sound in the voice. This will help the patient feel he/she has called an office with wonderful, caring people on staff. “The doctor must be nice,” the patient will think, “to have such nice people working with him/her.”
B. Reception. Entering the office should reinforce the impression created by the telephone conversation: “This office has a doctor and staff who care about their patients.” Your office should be neat, clean, and appear well organized.
C. Arriving. Staff members should be neat, clean, and well groomed. Uniforms will help create a good image. The patient should be greeted with a smile and addressed by name.
D. Sign in. Paperwork should be made easy. Your CA should observe the patient as he/she completes the sign-in paper work or attempts to complete it. In the event there is evidence of difficulty, your CA should immediately go to the patient’s assistance. Remember, some people may have difficulty reading or understanding the questions. Don’t allow your patient to feel embarrassed by admitting he/she cannot read or understand. YOUR PATIENTS SHOULD FEEL YOUR HELPING HANDS ARE EVER PRESENT.
E. I CARE. Show your new patient that you are different. Step into the reception room and say, “Hello, I’m Dr. Jones, and I’ll be with you in a few minutes.” This gesture of caring will do much to instill confidence in your patient, demonstrating that he/she has made a good decision to seek your help.
F. Exam room. If the patient is taken to the exam room and will not be seen for 3-4 minutes, be certain you or your CA stops by to assure the patient that he/she is important and hasn’t been forgotten. If another member of the family has accompanied the patient to the office, ask the patient if they would like to have the family member in the exam room. Do all possible to make the patient comfortable and secure.
History taking is an acquired skill and very important. Once you recognize the true value of a good history you will want to improve your skills. An in-depth history will give you an insight into past illnesses and injuries, the treatment and the outcome.
The primary data you should initially ask for are name, address, phone number (best time to call), type of work, recreational activities, and primary care physician. Managed care is here to stay; learn to work with it and it can be your ally. Send your examination report to the primary care physician, as well as your outcome report. By doing this you will build a rapport with the doctor and you will find referrals will be forthcoming. Your communications are very important in building inter-disciplinary cooperation.]
The doctor who is skilled in history taking enhances the accuracy of the ultimate diagnosis. Interaction with the patient will develop a greater level of confidence with the patient. Remember, your new patient may be apprehensive of what your examination will reveal. Patients forty years of age and up should be given a good physical examination every two years. Patients fifty years of age and up should receive a comprehensive physical examination annually. These examinations are like an insurance policy: It is very important to detect developing problems at the earliest possible moment. Many doctors fail to make blood and urine analysis a part of their examination. Don’t make that mistake. Always address the patient’s primary complaint; however, do not fail to examine the patient in sufficient depth to detect any underlying problems.
Perform all the services necessary to determine the best treatment plan for each patient. Don’t be afraid to make a referral when you can’t deliver the service yourself. Whenever I referred a patient, I always gave him/her an appointment to return for re-examination, to determine if the referral doctor was accomplishing his mission. I never charged the patient for this examination. It was my patient and I wanted to know that the patient was receiving the proper treatment. In the event the patient was not responding as anticipated, he/she was referred to another doctor and the same procedure was followed. Patients are impressed with this type of care and concern from their doctor. This creates a very strong bond between doctor and patient, and these patients make many referrals of friends and family. They will remain your patients for many years.
Your communication skills will have a major impact on the outcome of your patient care. Once your examination is completed you will explain your findings to the patient and outline your treatment plan.
To be truly effective, you must use words the patient can understand. Don’t try to impress him/her with big words. I’m going to share with you a procedure used in our office. The patient’s examination has included X-rays and orthopedic, neurologic, and proprioceptive evaluations. An appointment to return for a report of findings and a treatment plan is made and the patient leaves the office. The patient gave you the best time to call, if necessary, when the history was taken. Call the patient or have your CA call the patient and say, “The doctor would like to have another member of the family with you for your report of findings, and he would also like to have you bring your regular bed pillow with you.” If the appointment time is not convenient for both parties to be present, set a time that will be agreeable. If the patient asks if there is anything serious, reply, “No, there is nothing to worry about. However, the doctor would like to have both of you present when he explains his findings.” Having two family members present for your report will prove to be a strong re-inforcement for better patient compliance with your treatment plan.
When your patient and the other member of the family arrives in your office, be certain your CA greets them and makes certain they are not kept waiting in the reception room. Your CA should escort them to the room where they will be receiving the report of findings. You should be very prompt, thereby reducing the anxiety that builds while waiting for the doctor. Be well prepared by having X-rays in the view box (not lighted), lab reports, etc.
Begin your report by relieving their fears: “I’m pleased to tell you that our examination has revealed that there is nothing serious; however, it is important that we take care of you now.” Explain what you have found and show the X-rays. Don’t talk “subluxation” (Your patient doesn’t know what a subluxation is and has little interest in learning. Your patient has come for help—not an education on Chiropractic.). Use terms like “joint misalignment.” Explain that a Chiropractor is really a neurologist.
Next, demonstrate how joint position can cause distortion and cause the body to fail to function normally: “Your nerves control the body—they affect blood pressure and heart rate—they affect the entire digestive system—endocrine system [adrenal, thyroid etc.] and they affect your muscles. We are going to help get your body feeling better.
“I’ll show you what I mean. Think of your body as a pile of bones that are tied together with ligaments and muscles moving the bones. I’m going to test the strength of your muscles [take the patient’s hand in your hand and move the heads of adjacent metacarpal bones back and forth as you explain]: There are little receptor nerve endings in the muscles, joints, and ligaments. From the lower half of the body the messages from the muscles, joints, and ligaments travel up the posterior column of the spine to a little junction box at the base of the brain. It’s called the gracilis nucleus of the medulla oblongata.
“From the upper half of the body the messages travel up the posterior column of the spinal cord to another junction box at the base of the brain. It’s called the cuneate nucleus of the medulla oblongata [be certain to touch your patient from the base of the spine to the occiput as you make the explanation]. The messages then cross over to the side of the brain called the thalamus; it acts like the post office and sorts out the various messages and sends the appropriate ones to the parietal lobe of the brain [touch the side of the head and then the top of the head with this explanation] The parietal lobe of the brain produces motor impulses. From there the messages are sent to the pons [side of head] and across to the cerebellum [opposite side of the head]. The cerebellum stimulates and inhibits muscle activity.”
“Now, we are going to test the strength of your arm muscles. Put your arm straight out in front of you. I’ll put my hand on your wrist and I want you to push your arm straight up to the ceiling. As you push up I’ll pull down. Now push up. Let’s test the other arm. Put it straight out in front of you. Push up.” In many instances, one arm will be weaker than the other.
If you find one arm weaker than the other ask the patient: “Do you feel the difference in the strength of your arms? Let’s test each arm once again.” Repeat the tests and ask the patient if he/she feels the difference in the strength of each arm. This is proprioceptive evaluation in the standing posture. If the right arm was weaker instruct the patient to stand on the outside of the right foot. Test the strength of the left and the right arm. You will find a positive proprioceptive response. The right arm will now be strong. Instruct the patient to stand normally and retest the right arm; it will test weak.
“You can see that the position of the foot affects the muscles. We want to do all possible to keep the muscles in balance so they don’t cause distortion. Balanced muscles help the joints hold their corrections. Do you understand why we must balance the feet to help the corrections hold?” If the patient or family member answer “no,” repeat the test and demonstrate the weakness. Adjust the foot and apply a figure “8” tape strapping to the pronated foot. Instruct the patient to walk five or six steps and test the strength of the arm. You will find you have maintained a positive proprioceptive response and the arm will test strong. Remove the tape and have the patient stand and take two steps. Retest the arm and it will demonstrate a negative proprioceptive response and the arm will test weak. Most patients will want you to proceed with the recommendation to balance their feet.
Next, have the patient sit in a chair. “We are going to test your arms’ strength while you are sitting. Put your arm straight out in front of you and push up to the ceiling. We are going to test the strength of your leg muscles while you are sitting [place your hand on the patient’s knee and ask him/her to lift the foot off the floor by raising the knee toward the ceiling].” Instruct the patient to push up while you push down. Test the opposite leg. Generally you will find the leg will be weak on the same side the arm tested weak. Ask your patient if he/she feels one leg is weaker than the other leg.
Now, kneel down beside your patient’s weaker side. Place your hand behind his/her back and push on the sacro-lumbar junction. Test the arm and the leg once again. You will have evoked a positive proprioceptive response. The arm and the leg will test strong. Move your hand up two or three inches and re-test; you will find this pressure ineffective. Now have your patient sit up straight, being certain the spine is positioned over the pelvis. Test the arm and the leg; they will test strong. A positive proprioceptive response results from more optimal joint position. Ask: “Do you understand why it is important that you maintain good sitting posture?” Have your patient sit in his/her normal posture, retest, and you will demonstrate the weakness. Test the patient with a Postural Back Rest (PBR) and you will find a positive proprioceptive response. Recommend a PBR to help create the good sitting posture habit.
Test the reclining posture. Have your patient back-lying on a flat examination table and explain, “We are going to perform the arm and leg test.” Stand at the head of the patient and ask him/her to extend one arm straight up to the ceiling, being certain that the elbow is not bent. Place your hand on the patient’s wrist and ask him/her to push back toward you as you push forward. Repeat the test with the opposite arm. Once again, ask the patient if he/she can feel the difference in arm strength (generally, the arm will be weak on the same side that previously tested weak).
“Now we are going to test the psoas muscle of the leg. Raise your leg up to here [stop it at about 45 degrees].” Toe the patient’s foot out, placing your hand on the ankle and instructing the patient to push the leg straight up to the ceiling while you push down. Be certain the patient does not pull the leg toward the mid-line. Test the opposite leg and you will find that the leg will generally be weak on the same side the arm tested weak.
Now position yourself at the foot and instruct the patient to move the leg out to about 45 degrees (one leg is straight and the other is moved laterally 45 degrees). Grasp each ankle and ask the patient to push outward as you pull inward. Repeat the test with the opposite leg. Once again you will generally find weakness on the same side. “Do you feel the difference in the strength of your legs?” Now stand beside the patient at the level of the pelvis. Palpate the anterior superior spine of the ilium. At this level move your finger medial one to two inches and palpate deep. You will be palpating the iliacus muscle. Generally you will find the iliacus muscle is tender on the side of muscle weakness.
Now explain: “If the muscles are stronger on one side of the body than the other, you will have distortion as the strong muscles overcome the weaker muscles.”
Allow the patient to position his/her regular bed pillow beneath the head in the same manner he/she does when going to bed. Now test each arm and each leg. If you still demonstrate weakness, test the patient with the Pillo-Pedic® cervical support pillow. Test each of the four sides. Generally, you will find one side will produce a positive proprioceptive response. When you find this edge test the leg muscles and then palpate the iliacus. In most instances you will find a positive proprioceptive response when testing all areas. The arm will test strong, the psoas will test strong, and the iliacus will not be tender.
Next, have your patient roll over on his/her side, with the weak side up. Stand beside the patient and ask him/her to raise the leg 45 degrees. Place your hand on the ankle and ask the patient to push up as you push down. Replace the Pillo-Pedic with the regular bed pillow and test. Instruct the patient to roll over and re-test. Ask if he/she can feel the difference when the proper neck support is provided. If “yes,” then say, “Do you see why you need a Pillo-Pedic?”
Where: Anywhere there is a gathering of people.
How: Gain permission from the property owner. Emphasize PUBLIC SERVICE.
Equipment: Posture Check®, flat adjusting table or examination table, straight back chair, exam forms (to collect primary data).
Do: Spinal examination, proprioceptive evaluation. Explain that you will call when you have had the opportunity to evaluate your findings.
Don’t: Talk Chiropractic! Don’t answer any questions: Questions and answers will be welcomed once evaluation of the findings is completed. Don’t let this service appear to be anything but a true Public Service. There is no charge or obligation.
The telephone call: “Mr./Mrs. Jones, we have evaluated your examination findings and are pleased to report that we feel you will be very interested in what we have found. We note that you like to play golf. How would you like to add distance to your drive and straighten out a hook or a slice?” If he/she plays tennis: “How would you like to put more power into your serve and pick the ball off the back line better?” Et cetera.
“If you would like to make an appointment and come in I’ll explain our findings to you. Remember, there is no charge for this service. If you would like to bring a friend with you when you come for your appointment, feel free to do so. When would you like to come and see me? [make the appointment] We could perform the same service for your friend if he/she would like to be examined. My phone number is _______; keep it and feel free to call any time you have a question, or if you feel I can be of service to you or a friend. I’ll see you on Friday at 3:30.”
Report of findings: Talk about his/her hobbies and work duties. Does he/she have any backaches, headaches, muscle spasms, etc.? Explain the Posture Check findings. Demonstrate the proprioceptive tests: standing, sitting, and reclining. Demonstrate the tape test if appropriate. Explain exercises that will be beneficial. Suggest corrective measures as indicated. Do not push to make office visits and adjustments mandatory. If exercise is the avenue of choice, offer to re-examine in three months. There is no charge. Remember, if you push, people will push back. Never give them the opportunity to resist. Always ask questions that tend to lead to a positive answer: “Do you want to improve your performance? Do you want to get rid of that backache? Do you want to get rid of that headache?”
You are in the people business. Learn to communicate. Practice your examination procedures and become efficient. Explain your findings in simple, easy-to- understand language. You will build a great practice and prepare yourself for a very successful career in Chiropractic.
About the Author
Dr. Greenawalt graduated from Lincoln Chiropractic College in 1948. He received postgraduate training at Northwestern College of Chiropractic in the field of orthopedics, which resulted in his DABCO. He is a member of the American College of Chiropractic Orthopedics.