Examination and Communication

Your window of opportunity to a successful practice

By Monte H. Greenawalt, DC, DABCO

Want to grow a stable, thriving practice? Well I’m here to tell you one thing: you’re in the people business, doctor, and convincing patients to “buy in” to your treatment plan requires more than “wowing” them with clinical knowledge. It requires a degree of character and confidence. It requires strong communication skills. It requires you to treat them with respect and know them better than they know themselves.

But really, it’s easier to do than you might think—your patients are just like you, after all.

Do Unto Others…

Everyone wants to go to a doctor they have faith in. You’re a doctor. So ask yourself: “Do I present an image of confidence and competence my patients can have faith in? Would I have faith in a doctor like me?” If not, your patients will lack confidence in you and your treatment plans.

Your patients want a strong leader who is compassionate, understanding and confident in their methods. They want to feel like they’re in good hands. If you lack confidence in your plan, your patients will as well, and they may try to take control and alter it. If you allow this to happen and the treatment fails, well…

You are the one to blame.

You want your patients to comply with your treatment plan, and they will so long as you’re confident and they understand why you have recommended it. Explanations should be stated in a clear and understandable manner and should include as little jargon as possible. Try thinking of what prompts you to do as instructed: most of the time, it’s the very same things that motivate your patients to do as directed.

You must remember that most patients are apprehensive and even reluctant to visit a doctor. It is incredibly important to set the stage and convince your patients they have made an excellent decision in visiting your office and not someone else’s.

Setting the Stage

The following steps will help instill patient confidence in you and your practice:

A. Phone Call Generally, the first contact your patient will have is with your CA over the phone. If you place a mirror by the telephone and instruct your CA to look into the mirror and smile every time someone calls, this will help them adopt a pleasant, happy and caring demeanor. This works wonders for the patient, who will feel they have called an office full of wonderful, caring people. They’ll think, “Oh, this person is nice! If the staff is pleasant, then the doctor must be as well.”
B. Reception Entering the office should re-enforce the impression created by the phone conversation (i.e., “this office has a doctor and staff who care about me”). Your furnishings do not need to be new; however, the 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 to be easy. Your CA should observe the patient as they’re completing their paperwork. If they seem to be having difficulty completing it, your CA should immediately assist them. Remember that some people may have difficulty reading or understanding the questions. Don’t allow your patient to feel embarrassed by admitting they cannot read or understand. They should feel comfortable at all times when in your office.
E. “I Care” Show your new patient that you are different. Take a brief moment to step into the reception room and say, “Hello, I’m Dr. Smith. I will be with you in a just a few short minutes.” Odds are, you probably haven’t experienced this level of care in other offices, and neither has your patient, who will be thinking they’ve made the right decision in seeing you.
F. Exam Room If the patient is taken to the exam room and will not be seen for 3 to 4 minutes, be certain you or your CA stops by to assure the patient that they are important and are not being 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 be with them. Do your best to ensure the patient feels comfortable and secure.

Making History

Whenever possible, the patient’s history should be taken in close proximity with no obstructions, such as a desk. Sitting next to the patient or across from them is preferable. Always talk with your patient and not at them. History taking is an acquired skill, but once you recognize how important this skill is, you will want to master it. An in-depth history will provide insight into any past illnesses and injuries and help you create a relevant and effective treatment plan. Some of the basics:

Name | Address | Phone number | Best time to call | Type of work | Recreational activities

You’ll also want to ask about their primary care physician. Managed care is here to stay, so you need to learn to work with it and treat it as an ally. After you’ve completed your tentative diagnosis and completed your examination, you’ll want to send your outcome report to their primary care physician. By doing this, you will build a rapport with their physician and garner more referrals from them and their professional network.

The doctor who is skilled in history taking will have more accurate and relevant diagnoses and treatment plans. And the more relevant the treatment is, the easier it will be to explain your plan to your patient, which instills confidence in you and your treatment. Also remember that your patient may have a certain amount of apprehension, even fear, of what your examination will reveal. So the more confident they are in your treatments, the better.

Treat Your Patient Like Family

You are a doctor. Your patient thinks you are a doctor. Don’t prove them wrong by failing to perform all the services necessary to determine the best treatment plan for them. If they are forty years of age or up, they should be given a good physical examination every two years. If they are fifty years of age or up, they should receive a comprehensive physical examine annually. These examinations are like an insurance policy: you hope to find your patient in perfect health, but want to detect developing problems at the earliest possible moment. Many doctors fail to provide the unique services they are qualified for as part of their examination. Don’t make that mistake. Always address your patient’s primary complaint, of course, but don’t forget to conduct an in-depth examination to be sure there are no underlying problems.

Don’t be afraid to make a referral when you can’t deliver the service yourself. Whenever I referred a patient, I always gave them an appointment to return for reexamination to determine if the referral doctor was accomplishing his or her mission. I never charged them for this examination. They were my patient and I wanted to know if they were receiving proper treatment. And in the event they weren’t, I referred them to another doctor and the same procedure was followed.

This is a demonstration of practicing with honesty, sincerity and integrity. Patients are usually impressed with this type of care and concern from their doctor. It creates a very strong bond between the doctor and their patients, inspires them to generate more referrals from their friends and family and encourages them to remain with you for many years. Remember, your patients are people just like you, so if you’re looking for the best way to keep them as a patient, just ask yourself, “How would I feel if I was in their shoes?”

Communication is Key

Your communication skills will have a major impact on the outcome of your patient’s care. Once your examination is completed, you will need to 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 them with big words.

I’m going to share with you a procedure used in our office:

  1. Collect the patient’s history as outlined above
  2. Evaluate the patient using X-rays, as well as orthopedic, neurologic and proprioceptive methods
  3. Schedule an appointment for them to return for a Report of Findings and treatment plan before they leave
  4. Request that your patient bring a family member in for the Report of Findings (they can help re-enforce the need for your treatment plan)
  5. If they ask if there is anything serious, assure them that everything is OK
  6. Call the patient or have your CA call the patient after the fact to ensure they can still make it to the next appointment, and reschedule it if you need to

The Appointment

Before your patient arrives, make sure you prepare their Report of Findings and take care of any potential obstructions that could prolong the report (e.g., have the X-rays in the view box not lighted). You want to make sure the report goes by as smoothly and quickly as possible so as to alleviate any pent up anxiety they may have. When your patient arrives for their appointment, be certain your CA promptly greets them and escorts them to their room for their report. When you meet with the patient, begin by stating,

“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 to prevent anything from arising in the future.”

Testing for Structural Alignment – Standing

Explain what you have found in an easy-to-understand manner (no subluxation talk) while you show them their X-rays and demonstrate how the nervous system and joint position can cause distortion and dysfunction throughout the body:

“Your nerves control the body. They affect blood pressure and heart rate, as well as the digestive and endocrine systems, which affect your muscles. We’re here to make sure they continue to do their job well so your body feels better.

“Now, I want you to 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 and move the heads of adjacent metacarpal bones back and forth.

“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. That’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 and it’s called the cuneate nucleus of medulla oblongata.”

Be certain to touch your patient from the base of the spine to the occiput as you provide the explanation.

“The messages then cross over to the side of the brain called the thalamus, which 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 as you continue.

“The parietal lobe of the brain produces motor impulses. From there the messages are sent to the pons, which is the side of the head, and across to the cerebellum, which is the 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 with your elbow straight. I’ll put my hand on your wrist, and then I want you to push your arm straight up to the ceiling. As you push up, I’ll pull down. Now let’s push up—push, push, push. Now let’s test the other arm. Put it straight out in front of you with your arm straight. Push up—push, push, push.”

In many instances, one arm will be weaker than the other. If you find one arm weaker than the other:

“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 they feel 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 right arm. You will find a positive proprioceptive response. The right arm will now be strong. Instruct the patient to stand normally and re-test the right arm. It will test weak.

“You can see that the position of the foot affects the muscles. We want to do everything 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 they don’t understand, repeat the test, then adjust the foot and apply a figure “S” 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. Re-test the arm and it will demonstrate a negative proprioceptive response and the arm will test weak.

“Do you understand why we must balance the feet?”

Most patients will want you to cast their feet and proceed with the recommendation to balance their feet. Have the patient sit in a chair, and then proceed.

“We are going to test the arm’s strength while you are sitting. Put your arm straight out in front of you and push up to the ceiling—push, push, push. 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 them to lift their foot off the floor by raising their 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 they notice if one leg is weaker than the other. Now, kneel down beside your patient’s weakest side. Place your hand behind their 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.

Testing for Structural Alignment – Lying Down

Now test their reclining posture. Have your patient lye flat on an examination table and explain that you are going to perform the arm and leg test in the reclining posture. Stand near their head and ask them 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 them to push back as you push forward. Repeat the test with the opposite arm. Once again, ask the patient if they can feel the difference in the strength of their arms. 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.”

The leg should be at 45 degrees. Toe the foot out, place your hand on the ankle and instruct the patient to push the leg straight up to the ceiling. Be certain the patient does not pull the leg toward the mid-line. If this happens, start over and insist the patient push the leg straight up to the ceiling. 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 of the patient and instruct the patient to move the leg out to about 45 degrees with one leg straight and the other moved laterally at 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.

“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 their regular bed pillow beneath their head in the same manner they do when they go to bed. Now test each arm and each leg. If you still demonstrate weakness, test the patient with the Pillo-Pedic®. Test each of the four sides. You will usually find that one side will produce a positive proprioceptive response. Test the leg muscles when you find this edge 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 their side with the weak side up. Stand beside the patient and ask them to raise their leg 45 degrees, then place your hand on their ankle and ask the patient to push up as you push down. Replace the Pillo-Pedic with their regular bed pillow and test. Instruct the patient to roll over and re-test. Ask the patient if they can feel the difference when the proper neck support is provided. If they confirm, reaffirm why it’s important for them to have a Pillo-Pedic and ask their family member if they will encourage them to use it.

Conclusion

Want to grow a stable, thriving practice? Well, now you can. Now that you know you’re in the people business and have learned that effective communication is key, and picked up a few examples on how to get the boll rolling with your patients, you are well on your way to establishing a successful practice. And if you’re already practicing successfully, implementing the tips and techniques outlined in this article will help you impress your patients with more than just clinical knowledge. With a strong personality and confidence in your treatment plans, you will be on your way to building a great relationship with your patients and preparing yourself for a successful Chiropractic career.

About the Author

Monte H. Greenawalt (1923–2007) 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 was a member of the American College of Chiropractic Orthopedics.

Dr. Monte Greenawalt was Chairman of Foot Levelers, Inc., of Roanoke, Virginia, which he founded in 1952, and was publisher of Success Express magazine. He held six US and foreign patents for his work in spinal/pelvic stabilization and proper cervical alignment.

As an author, Dr. Greenawalt’s articles have appeared in many national and state publications. Since 1977, he has contributed more than 40 articles to Success Express on the subjects of Chiropractic and motivation that provide useful lessons and tenants to this day. He was a strong financial supporter of the Chiropractic profession, its associations and colleges, and constantly urged Doctors of Chiropractic to actively support the growth and development of their profession. He was known for his positive attitude and unselfish work, and was the recipient of many awards and honors.