Q: I had a question about the paternalization of patients. There has to be a point where the doctor has to guide the patient to make their own decisions, but where is the line in the sand where you have to push the envelope a little? For example, you offer your 3X/week recommendations to the patient and they say, “I cannot do 3X/week, but I can do 2X/week.”
Where do you draw the line to accepting what they feel to be true (beliefs) or tell them, “Do you think you will get the optimal benefit if you come in 2X/week? Where is the difference between the bending point vs. the breaking point and the DC down the street “…who will see you 2X/week but I am not going to sacrifice your health or my reputation, especially if you do not get your desired result?”
A: You raise a common question about the occasional negotiations that can ensue with a patient about visit frequency. My answer is based upon a core belief that you and I may or may not share. And that is this:
Patients are volitional beings, granted free will by their Creator. You have no control in what patients do with your recommendations, or whether they will ever show up to receive them. You can attempt to influence their decisions, but you have no control, other than to recommend they see a different chiropractor. The only control you have is if, when and where you adjust them—if they show up. Imagining you have any other control, including the speed of their recovery or any other aspect of your relationship with them is merely an illusion.
If your dentist recommends daily flossing and you choose to overrule his or her recommendations in favor of your own hit or miss frequency, are you inclined to blame the dentist if a subsequent examination shows continued gum erosion? Probably not.
And you’ve probably heard of the countless chiropractic missions to the Dominican Republic, Panama and elsewhere, where a bevy of chiropractors will adjust tens of thousands of patients—once. Which raises the question, is one adjustment in a person’s life better than no adjustment? I assert that one is better than none.
Now, superimpose these observations on the question you have posed, and my response might sound something like this:
“I understand. Naturally, my recommendations of three times a week are based on seeing results with hundreds of other patients with similar health issues. What we’re doing with repeated adjustments is retraining and repatterning the muscles that support your spine. Like frequent visits to the gym, it takes time and repetition to make the necessary changes. My concern with fewer visits is that we won’t create enough momentum to make a difference. It’s a lot like the space shuttle. When it blasts off, if it doesn’t go fast enough, it never gets into orbit. Now, do I think two visits a week are better than no visits a week? Absolutely. But I’d be a bit concerned that we may not make a lasting difference.
“What would you like to do?”
There. You’ve explained it in terms that most patients will understand, maybe even believe. You’ve made your optimum, look-yourself-in-the-mirror recommendations and the matter is officially out of your hands. You haven’t made the relationship about you, and you’ve demonstrated that you care. You’ve shifted responsibility to the only individual with the “ability to respond,” the patient.
Ultimately, this is about creating, and enforcing, professional boundaries. Worrying about your reputation, attempting to impose your will, shielding patients from the “failure” of a subsequent relapse or shaming them into care they don’t want (or understand) is not only parental, it’s unsustainable if you have any hope of helping a lot of people.