The Patient-Centered Chiropractor

Virtually every chiropractor I've met would agree that their primary obligation in practice is to do the best they possibly can for their patient. In fact, every practitioner of any discipline I've ever met would say the same thing: "It goes without saying." Or does it? Looking at the agenda of most chiropractic meetings, practice management seminars and publications; you would think that the chiropractors' first obligation is to us. In fact, even discussions among individual chiropractors typically center on practice-building, billing and politics, although clinical questions do arise. But even these are geared toward skill-building, as opposed to doing something faster, cheaper or more effective for a patient. In fact, a great deal of the clinical discussions I hear involve getting patients to comply with care, keeping appointments, etc.

At the professional level, the chiropractic identity debate rages on, as it has for more than a century, and nowhere to be found in the discussion is how DCs can do a better job for their patients. Are we spine care, NMS, subluxation-based, or primary care/wellness? How do we survive? How do we increase market share? How do we gain cultural authority? How to we preserve or expand insurance coverage? How do we maintain health care parity/equality? How do we get our agenda through COCSA? For the most part, even our research agenda isn't focused on projects aimed at "improving" chiropractic procedures for our patients. Rather, it is frequently about "proving" something we believe in or developing a product or service we can bill for. The patient - who's that?

Reduced to its simplest concept, patient-centered care might simply be the golden rule. But it involves a lot more than the ethical mandate of doing the right thing. It also entails doing the best possible thing. Don't get me wrong; health care, including chiropractic, is a business, and a great deal of energy and resource needs to be put into developing, maintaining and promoting sustainable, profitable, ethical business models. But that's a topic for another day. Much of our chiropractic practice focus seems to be greedily geared toward individual marketing strategies aimed at pulling an individual patient into an individual chiropractor's office, despite the fact that research indicates this kind of approach alienates more patients than it attracts.^1,2

More than a decade ago, the Pew Health Professions Commission issued a report on patient-centered care, outlining specific knowledge, skills and values involved in providing such care.³ Several areas associated with the doctor/patient relationship were identified for which knowledge, skills and values are critical. These areas included the doctor's own self-awareness, his or her appreciation of the patient's experience of health and illness, developing and maintaining caring relationships, and effective communication (see Table 1). Although these skills may be modeled in training, dedicated focus to these skills typically is neglected in medical or chiropractic school.

Further, and even less likely to ever be addressed or modeled in school, are knowledge, skills and values involved with the practitioner/community relationship. Areas such as the meaning of community, what contributes to health within the community, developing and maintaining community relationships, and effective community-based care all must be addressed thoroughly in order for a practitioner to be perceived as an important resource in the community, rather than as just another slick (or even greedy) business enterprise.

The Pew report even addressed knowledge, skill and value needs in terms of practitioner/practitioner relationships. Self-awareness, traditions of knowledge in health professions, building teams and communities, along with working dynamics of teams, groups and communities, along with working dynamics of teams, groups and organizations, are areas in which practitioners need to be competent to get along well with others. These skills might have offered great value to chiropractors had such areas been imbued into our culture.

In short, if chiropractors and chiropractic are ever to truly become, and be perceived as, patient-centered, we will first require a paradigm shift regarding our own "agenda." Instead of trying to find a way to convince everybody else to adopt our way of thinking so that we can achieve the respect, integration, and cultural authority to which we aspire, we should figure out what we need to do to become a valuable individual and community resource for others.

And then, we need to get about using the immense talents within our profession to develop, refine and disseminate ethical, successful practice and/or business models that readily incorporate tools for evidence-based decision making and meaningful outcomes management that can be applied to individual, group and integrated practice settings.

References

1. Hawk C, Killinger LZ, Dusio ME. Perceived barriers to chiropractic utilization: a qualitative study using focus groups. J Am Chiro Assoc 1995;32(6):39-44.
2. Environics Research Group. Attitudes Towards the Marketing of Chiropractic Services. Mississauga, ON: Ontario Chiropractic Association, 2006.
3. Tresolini CP, Pew-Fetzer Task Force. Health Professions Education and Relationship-Centered Care. San Francisco, CA: Pew Health Professions Commission, 1994.