Patricia called me from 70 miles away. There was desperation in her voice. "Will it make me better?" She's hoping for some magic that she didn't encounter in her first two years of treatment with chiropractors. Now a chiropractic doctor has told her that her x-rays definitely indicate need for care.
Patients want to know is this treatment necessary? Tell me yes or no. They ask, "Will it make me better?" And they mean "all better" like they were before. Sometimes they say, "Will I attain some idealized state of health?" And the question is like a freshman asking whether he'll become the quarterback.
They want a black and white world, rather than the uncertainty of shades of gray. They want you to tell them yes or no, stop or go. They want a definite, clear answer. Shades of gray are stressful to them, and they are motivated to avoid this stress.
Doctors and patients both slip toward unethical behavior because of unfortunate tendencies of human nature. "People rarely act according to a set of consistent standards. Rarely do they examine the evidence and then form a conclusion. Rather, they tend to do whatever they want to do and to believe whatever they want to believe, and then find whatever evidence will support their actions or their beliefs. They often think selectively: In evaluating a situation they are eager to find reasons to support what they want to support and they are just as eager to ignore or disregard reasons that don't support what they want."1
There's a conflict of interest between giving a potential patient accurate information and affecting them emotionally, so they'll buy your treatments. When you're a good doctor, you can't promise a cure. When you're a good salesman your positiveness, enthusiasm and confidence will enable you to close the deal.
"Will it make me better?" is a loaded question. Sometimes the honest answer is one that we don't want to say, and the patient doesn't want to hear. Do you tell patients and their payers in a timely manner when the answer is one of the following?
"Only a little" or "We've done as much for your condition as we can. When new problems come up, we'd be glad to help" or
"You have to decide if the amount of better you feel makes coming to the treatments worthwhile" or
"The 1993 Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference recommend implementation of up to two independent treatment plans relying on repeated use of passive care, in cases undergoing prolonged recovery. In therapeutic trials, significant improvement should occur by two weeks. Symptoms that remain unchanged for two to three weeks should have treatment plans altered to de-emphasize passive care and refocus on active care approaches. (8.4.1) (8.6.1)"2 or
"Standards of necessity consistent with generally accepted professional standards proscribe that these types of treatments at the frequency of more than twice a week are only medically necessary in cases that are acute, not chronic."3
X-rays are a moral quagmire that we deal with every day. How many times has x-raying a patient actually changed your diagnosis? There are valid questions about whether x-raying patients is actually chiropractically necessary. A major reason we are using x-rays as a diagnostic test is that the films are good defensive medicine in the rare occurrence of a malpractice suit. Do we let our potential patients know this? Or do we withhold this information from them, even when they are in circumstances that are low in medical necessity for the procedure and they communicate their concern about the cost?
Most chiropractic doctors I know will admit that the main value of x-raying new patients is it makes patient management much easier for the doctor.
Does the amount of "patient education" obtained from the patient's series of films actually justify the cost? Does the way we value chiropractic really mean we have a moral imperative to use whatever means necessary to get people to accept our treatments?
Generally, do you help your patients examine the evidence in their whole situation and then form a conclusion? Or are your patient management office procedures geared to leading patients or emotionally manipulating patients, so both patient and doctor fall prey to the tendency of human nature discussed above, being too eager to find reasons to support what you want to support and ignore or disregard reasons that don't support what you want.
Do you understand where you have conflicts of interest and how you are behaving in situations of conflict of interest? Are your communications deceptive? Do you misrepresent? Do you coerce?
It was unethical to lead Patricia to believe that there are signs on her x-rays that override other factors and indicate a definite need for care.
References
- Gula, Robert: Nonsense, How to Overcome It. Stein and Day, New York, 1979, p.15
- Scott Haldeman, David Chapman-Smith, and Donald Petersen, eds., Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference. Gaithersburg, Maryland: Aspen Publishers, Inc., 1993, pp. 124-125.
- Ibid. p. 125.
Linda S. Elyad, DC
Phoenix, Arizona
