Patient Education and the Continuum of Health

In the first installment of this column,¹ I reviewed the biomedical model and the health-related quality of life model as a means of providing chiropractors with a grasp of the current shift away from a diagnostic/pathology paradigm, toward a functional approach for the vast majority of patients with musculoskeletal conditions. The reason for this shift, incidentally, was very recently explained by Teasell and Harth² in 1996. "The failure of the medical model in relieving the pain, suffering and disability of chronic low back pain has led to a gradual switch in management strategy characterized by the functional restoration approach. The focus is no longer on diagnosis or treatment, but on maximizing functional abilities."

In this installment, we will examine how to utilize the latest concepts of health care as a practical means of educating patients, health professionals, third-party buyers, attorneys, judges and jurors.

To enhance the appreciation and credibility of chiropractic's unique approach, it's important that the education we provide offers insight into our nonmedical paradigm. Recently, I've been using the term nonmedical, not alternative or unconventional, because as Carey, MD, MPH³ concludes in a 1996 study, the "use of chiropractic is so common that one hesitates to use terms such as alternative or nonstandard."

What We Want Our Patients to Know

It's important that our patients understand that in chiropractic, our emphasis is on health, wellness, and optimal function, not the treatment of diseases or symptoms. Of course, a chiropractic education trains us to identify serious pathology, manage it when it fits within our scope of practice, or to refer when appropriate. Nevertheless, for the vast majority of our patients, the goal is "to rehabilitate rather than medicalize," as Waddell, MD⁴ noted in 1992. We provide a more holistic and functional approach to health care in which the patient's activity tolerance, well-being and quality of life are at the center of care and not the treatment of symptoms.

It's enormously valuable if we can educate our patients to appreciate that from a chiropractic vantage point, health is more than the absence of symptoms. It is viewed in positive terms of:

1. optimizing human potential
2. enhancing the quality of life
3. restoring function
4. boosting the resistance to disease
5. improving vitality
6. increasing strength, endurance, balance and coordination

In chiropractic, the intent is to assist in restoring and maintaining a "lifestyle that creates the greatest potential for personal well being," as noted by Coulter, PhD⁵ in 1993. This approach is inherently appealing to patients today. It acknowledges their own highest aspirations, their wish for health care which focuses on enhancing their ability to function in the real world. This is the most meaningful and rewarding outcome from a patient's perspective. It is pivotal to make the benefits of chiropractic directly relevant to patients' personal health goals, focusing on restoring and optimizing function of the activities which are most important in their daily lives. As is noted by the Health Outcomes Institute⁶ in 1993: "Patients judge the effectiveness of care by its impact on their lives. They want to know whether the treatment will relieve pain, improve their ability to see, hear, walk, or function in other ways. Providers have not taken these outcomes seriously enough."

Our approach then is positive, encouraging and personalized, or as described in the current literature,⁷ providing a sense of hope, an opportunity to achieve higher levels of functioning, well-being, general health and quality of life. Phillips, DC, PhD, DACBR⁸ acknowledged these as essential goals of holistic care in 1994 stating: "The purpose of care is to restore the whole person and not to treat isolated symptoms or diseases. When the patient is the center of care there is an emphasis on understanding the personal and human aspects of health and illness, as opposed to only the biological effects." It is just such a supportive and responsive approach which patients find attractive, validating their own perspective on what is truly important in their lives and health.

The Continuum of Health

Optimal Health/Optimal Fitness
Fitness
Wellness
Good Function
No Symptoms
(Asymptomatic Dysfunction or Pathology)
Minor Symptoms/Dysfunction
Moderate Symptoms/Dysfunction/Pathology
Severe Symptoms/Pathology/Disease
Death

This illustration represents the full spectrum of health care, depicting the positive and functional dimensions of health which are highly valued by many people, but often neglected in medicine, and the traditional concerns of pathology and disease. At the top of the chart are portrayed the ideals of optimal health and optimal fitness. Immediately below them are other positive dimensions and goals of health care. These concepts are currently being seriously studied by health psychologists and exercise physiologists, but are not routinely promoted as health goals in our disease-oriented medical system. As Meador⁹ noted in 1994: "Clinical medicine can only say, 'with the methods we used we found none of the diseases we looked for.' We have a diagnostic system that can find only disease, not wellness."

By featuring good function, wellness, fitness, optimal health/fitness prominently in our educational materials, we communicate to patients that they are central concerns and outcome goals of chiropractic; that our focus is on health rather than disease. Our emphasis on the positive dimensions of health help patients to appreciate that we offer something unique and distinctly different from traditional medical care. Our purpose, as Phillips¹⁰ and co-authors eloquently stated, "is to optimize the patient's physical, mental and social well-being, structurally and functionally, focusing on the whole person, thinking of health as not merely the absence of disease, but in terms of human potential."

At the bottom of the chart are the advance degrees of health problems including severe pathology and disease. It is in this area that MDs are best trained and most proficient. The orientation of medical education is focused on differential diagnosis of diseases. Clinical training in medicine is almost exclusively hospital based so that medical students are trained on patients with advance pathologies. Such patients do not reflect the full spectrum of those seeking health care, but represent instead only one extreme end of the continuum and point toward a bias in medical training toward advanced disease processes. Many patients, as was discussed in the first installment of this column, have functional disorders in which there is no diagnosable structural pathology. As the 1994 AHCPR's Acute Low Back Problems in Adults¹¹ states: "Even after an extensive workup, only about 15% of patients can be given a definitive diagnosis." Waddell¹² noted this shortcoming of the biomedical model when he state in 1992:

"The failure of medicine is in the treatment of common nonspecific back pain which doesn't fit the model. If back disability is a result of physiological impairment rather than structural pathology, then the disease model is neither appropriate nor effective. many specialists involved in the treatment of back disorders are inappropriate for the majority of patients with LBP. Orthopedic surgeons with a primary interest in fixable structural problems should not dominate research, treatment and teaching of LBP. Rheumatologists with a primary interest in inflammatory arthropathies or any other medical specialists constrained by the disease model are equally unsuitable."

These statements underscore the distinctions between our orientation and that of traditional biomedicine. The contrast between these two paradigms is further characterized by Gatterman:¹³ "The medical reductionists narrow field of vision delays treatment until the pathological process can be identified. The holistic provider strives to improve function and enhance the body's own curative effort, its inherent capacity to heal."

As was reported in the influential Eisenberg study¹⁴ in 1993, about a third of the general patient population are seeking various forms of nonmedical care without a medical referral. Blevins,¹⁵ in her review of the Eisenberg study, stated that about 70 percent of the costs of receiving nonmedical care were out-of-pocket, while only 17 percent of the costs were our-of-pocket if patients saw a traditional medical doctor. She concluded that large numbers of patients were seeking nonmedical care despite strong economic disincentives.

Eisenberg's findings were bolstered by the results of a 1996 study¹⁶ of more than 3,000 patients in Southern Australia by MacLennan, et al. They found that of the large sample surveyed, at least one nonmedically prescribed alternative medication was used by 48.5 percent of people. In addition, 20.3 percent had visited an alternative practitioner, most commonly DCs (15 percent). The study "suggests that alternative care provides benefits lacking in conventional doctor-patient encounters, including time, empathy, personalization, expectation of a cure in chronic conditions, counseling, and emphasis on health rather than disease." They caution: "It is important to examine why and how conventional medicine has seemingly failed to provide them."

An enormous part of our appeal, therefore, and a primary reason that chiropractic care is making such deep inroads into the health care marketplace, is that we do provide them. Our personalized, patient-centered care offers and acknowledges the goals most important from a patient's point of view: the healing potential of caring and empathy; esteems each patient's perspective and experience of illness; seriously regards the functional outcomes that increase patients' ability to perform activities of daily living; enhances the quality of life and well-being. As Katz¹⁷ recently noted, outcomes "measuring function, symptom severity, health status and patient satisfaction ... in 1996 should no longer be regarded as curiosities, but rather as indispensible..."

Maintaining an educational approach which is consistent with these principles, this emphasis on patient-oriented outcomes, this sensitivity to what is important to patients, will be vital in the growth and demand for chiropractic in the future. The trend is clear and being consistently acknowledged in the current literature. As a commentary by Weisel, MD,¹⁸ in 1996 recently demonstrated: "Given the popularity of chiropractors with their patients and the depth of scientific evidence in favor of SM, it will be interesting to see if DCs begin to take a larger share of the BP market. Currently about 30 percent of people use DCs. It DCs make inroads into the other 70 percent of the population, there could be an explosive growth of chiropractic services."

References

1. Slosberg. Dyn Chiro, 1996:May 20:32,36,27.

    

2. Teasell, H. Spine, 1996;21(7):844-47.

    

3. Carey, et al. Spine, 1996;21(3)339-44.

    

4. Waddell. Bailliere's Clinical Rheumatology, 1992;6(3)Oct:523-57.

    

5. Coulter. J Canadian Chiro Assoc, 1993;37(2):97-103.

    

6. An introduction to the Health Outcomes Institute's Outcomes Management System, 1993:1-5.

    

7. Beuskens. Spine, 1995;20(9):1017-1028.

    

8. Phillips. J Chiro Humanities, 1994;4(1):20-25.

    

9. Meador. New Eng J Med, 1994;330(6):440-441.

    

10. Phillips, et al. J Chiro Humanities, 1995;4(1):20-25.

     

11. Bigos. ALBP in Adults. AHCPR, Dec. 1994:8.

     

12. Waddell. Bailliere's Clinical Rheumatology, 1992;6(3):523-557.

     

13. Gatterman. J Altern Complementary Med, 1995;1(4):371-386.

     

14. Eisenberg, et al. New Eng J Med, 1993;328(4):246-252.

     

15. Blevins. Policy Analysis, 1995;Dec, 15:1-36.

     

16. MacLennan AH, et al. Lancet, 1996;347(March 2):569-573.

     

17. Katz. Spine, 1996;21(8):963.

     

18. Wiesel. Backletter, 1996;11(3):36.

Malik Slosberg, DC, MS
Pleasanton, California