Out of Bounds

by William D. Esteb

Much of the frustration and suffering among chiropractors is the result of poorly defined boundaries between themselves and their patients. When physical, social, financial and clinical boundaries are blurred or vague, many chiropractors get sucked into a vortex of disappointment and ultimately, burn out. This is an inherent fundamental risk for virtually all professional caregivers. The solution is often seen as painful, and is rarely attempted until the pain of establishing clear boundaries is eclipsed by the pain of not having or not abiding by them.

Unlike a continuing border skirmish between adjacent third world countries, boundary disputes between chiropractor and patient are rarely overt. This a much more subtle conflict. Rather than the use of live ammunition, the clash involves a form of psychological warfare that employs the weapons of guilt, regret, resentment, misunderstanding, unmet expectations and a self-imposed sentence of failure or feeling of impotence.

Clinical Boundaries

Knowing and acting on a clear delineation between your responsibility and the patient’s responsibility is the essence of this rarely discussed problem. Compound this with the temptation to care about the patient’s health more than the patient, and many chiropractors find themselves in a painful co-dependency that removes the joy from practice and, in its later stages, can actually serve to push patients away.

It is your responsibility to uncover the patient’s health goal. It is your responsibility to conduct a thorough examination to determine if the patient is a good candidate for chiropractic care. It is your responsibility to explain your findings in a meaningful way. It is your responsibility to present a care plan that maximizes the likelihood that the patient will achieve their health goals. It is your responsibility to be available to deliver care at the time and frequency you propose during your report. And, it is your responsibility to monitor their progress and to modify, if necessary, your suggested care plan.

However, it is the patient’s responsibility to declare the symptoms of their health problem and to identify the desired outcome. It is the patient’s responsibility to evaluate your recommendations, and to act on them or reject them. Simple, really.

The trouble begins when chiropractors ignore or blur this clear demarcation of responsibilities. Taking it personally when patients decide not to follow their recommendations. Becoming offended when patient behaviors endanger the speed or effectiveness of their care plan. Succumbing to feelings of disappointment or powerlessness when patients discontinue care prematurely.

“Was it something I said?” “Was it something I did?” “Was it something I forgot to do or say?” “It must be my fault.”

If a high percentage of patients produce this type of self doubt by snubbing your highest aspirations for their health, your concerns may be well founded because you have invested yourself in something out of your control and responsibility. A classic case of blurred boundaries.

Financial Boundaries

As a result of the changing third-party reimbursement environment, vague financial boundaries are an increasingly common source of suffering. If you have trouble with collections, frequently have to send out past-due reminders, write off large sums of uncollected accounts, resort to small claims court or worse, you have unclear or unenforced financial boundaries with patients. This is all made worse by self-esteem issues, new patient scarcity concerns and the incorrect notion that running a profitable business is somehow an admittance to poor clinical skills.

Inappropriately caring about the patient’s health to such a degree that you allow yourself to fall out of fair exchange, permitting high uncollected balances and endangering the solvency of your business, are all too common situations.

“If I enforce my financial policy, the patient is likely to leave,”

That’s it, isn’t it?

The implication is that you think your service isn’t valuable enough to prompt someone to pay for it. That must be very painful. How did you become so deceived? Is it because you wouldn’t pay that much for your services?

What patient would refer their friends to a chiropractor who doesn’t have enough self-respect to demand to be paid? Those patients without such a conscience refer their deadbeat friends to similarly abuse you. Soon, you start thinking no one is available who can actually pay for their care. Except of course, the equally abusive insurance companies.

Clarify who you want your boss to be. Is it the patient or a managed care organization? Decide, because whenever you attempt to serve two masters, you will love the one and hate the other. Put your financial policy in writing. Identify your fees, how and when they are to be paid, how much credit (if any) you’re willing to extend to patients and the consequences to the patient when they do not keep their account current. Have the patient sign it. Then, the hard part. Rigorously enforce it. And yes, some patients will leave. Or perhaps you’d prefer that they run up a big bill first?

Social Boundaries

True health is defined as “…optimum physical, mental and social well-being, not merely the absence of disease or infirmities.” Social well-being, especially in a doctor/patient relationship requires clear boundaries, too. Without them, the ability to deliver chiropractic care can be compromised.

This social dimension isn’t about creating rapport and being a good communicator. It has to do with the implied social contract that happens when a patient seeks the resources, talent and care that you offer. This social dynamic is tempting to abuse and exploit. For both parties! The doctor may be lured by the prospect of control, power or authority. And the patient may be enticed to take a passive role, abdicating his or her responsibility, showing up to be “fixed” without any active involvement.

The trap is laid during the early stages of the relationship, as the patient responds beautifully to chiropractic care. Once the patient has achieved the symptomatic relief they originally sought, they discontinue care. The chiropractor, like a jilted lover after a one-night stand, feels hurt and betrayed.

Remember, the patient is the master. You’re the servant. The master hires and fires. The servant attempts to meet or exceed the expectations of the master. Confuse these roles by trying to reverse them or by simply ignoring them and you cross an important boundary line.

A Loss of Power

Nations, cultures, professions and products are advanced by increasingly higher standards. When you practice, without clear boundaries between your responsibilities and the patient’s responsibilities, you diminish your power and influence. By standing up for yourself, by clarifying your professional boundaries, by saying “no” when appropriate and by risking rejection, your self-esteem soars. Ultimately, the patient benefits when you have the confidence to ignore the expedient, short-term solution and instead, do what’s right in a more eternal time frame. When you’re willing to risk not being liked, you open the floodgates to something even more valuable, being respected.

Excerpted from
Connecting the Dots
Published in 2005
240 Pages
US $24.95

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