Because many young graduates focus so heavily on their education, they fail to develop a solid identity of their role as practitioners. They must acquire the skills required to balance the desire to care versus the desire to cure. Rather than ordering more tests, or performing more procedures to avoid confronting the uncertainties and confines of everyday chiropractic practice, they must learn to provide their patients with more comfort and support.
According to Ian McWhinney, professor of family medicine at the University of Western Ontario, healing is not the same as treating or curing. Healing happens to a whole person, i.e., a patient can be cured without being healed. Someone who remains in anguish of spirit, even after physical recovery, cannot be said to be healed.
When doctors abandon their interest in patient-centered intellectual and spiritual values, they have become therapeutic materialists. A characteristic indication of being in such a state is becoming preoccupied with such things as spinal listings, diagnostic procedures, laboratory tests, and the currently popular MRI and CT scan. While these concerns are certainly indispensable to any responsible clinical practice, they must not be taken to be the end-all or be-all of patient care.
In contrast with the open-ended questions mentioned earlier, there are also closed-ended questions. Traditionally, they constitute the bulk of most conventional case histories. They are comprised of questions eliciting either a yes/no response, or a brief reference to the complaint that initially caused them to enlist professional help. Common examples of closed-ended questions are: Where do you feel the pain? How long have you had it? Is it sharp and stabbing or dull and aching? Have either of your parents ever had back trouble?
The traditional chiropractic model does not stress communication skills as central to its practice. An increased emphasis should be placed on doctor/patient communication and the fact that improved doctor/patient relationship are, indeed, both teachable and learnable skills.
The doctor/patient interaction is slowly but surely acquiring a more egalitarian status, one in which a patient's strengths and weaknesses are seriously taken into therapeutic account. A cooperative rather than an adversarial relationship between doctor and patient has begun to emerge. Once patients realize that they can and must play an integral role in the healing process, they will no longer dread its previously depersonalizing side effects. Any conventional hospital stay can illustrate the extent to which patients are often treated as if they were at one with their pathology.
A recent study of the impact the doctor/patient relationship has on the outcome of chronic disease revealed that the greater the patient control (in the form of questions and answers) exerted during office visits, the greater the improvement in blood sugar and blood pressure. Conversely, the more doctor control exerted, the more elevated was the blood glucose and blood pressure. A study by Kaplan, Greenfield, and Ware has shown that the less information doctors supply their patients, the poorer their health outcomes. It has been estimated that in the average office visit, 60 percent of the dialogue is doctor talk, whereas, only 40 percent is patient talk. This equation will vary somewhat, of course, with circumstance and individual personalities. One thing does appear self-evident -- a great many doctors tend to monopolize the health care dialogue.
Does the nature of the doctor/patient relationship affect the patient's health status? It has been estimated that approximately 23 percent of a routine office visit is taken up with the doctor asking questions. It therefore follows that any verbal exchange between doctor and patient is endowed with the capacity to significantly influence psychophysiological processes. Hopefully, the doctor/patient relationship, as we move into the next century, will shift more and more in the direction of interaction and egalitarian participation, centering on patients as people, taking into account their individuality and cultural strengths and weaknesses. The cooperative healing process is not only enhanced by acknowledging a patient's attributes and intelligence, but also by showing a genuine respect for their contribution to the therapeutic alliance.
It is a reasonably well-established fact that you, as a doctor of chiropractic, will attract a particular type of patient. Aside from your professional ability, your personality and character will account for the kinds of patients you will attract. Your ability to communicate with your patients in a meaningful manner will often carry more weight than your ability to simply dispatch verbal messages.
If you are a communication-sensitive practitioner, you are surely aware of the fact that your patients do not come to you as a blank slate -- a tabula rasa. They come not only with problems having a cause and effect, but also armed with their own special ideas concerning health and disease. Frequently, they come with both a self-made diagnosis and a preconception about how they think it should be treated.
Patients and their preconception or misconceptions, right or wrong, real or imagined, should not be ignored. Why? Because their beliefs are capable of influencing the course, character, and outcome of your treatment. Perhaps you've read about the physician who encouraged his pediatric cancer patients to draw a picture of their cancer and, daily, make it smaller. Ideas, indeed, have physiologic consequences.
Entry into your patient's world is, at best, extremely difficult. It demands that you shift your focus from being illness-centered to patient-centered. You do not treat backs, necks, or shoulders but, rather, people with backs, necks, and shoulders. Disease is an abstraction -- a malfunction of the body machinery; illness is the unique expression of someone who feels ill.
The traditional chiropractic/medical model explains sickness in terms of pathophysiology -- abnormal structure and function of systems, tissues, and organs. Sickness is reduced to dis-ease. The focus is the body, not the person; the social and cultural contexts are irrelevant to the doctor's central task of diagnosis and cure. Disease and illness however do not always coexist. Patients with an undiagnosed, asymptomatic disease are not ill; people who are grieving or worried may feel ill, but have no disease. The significance of this distinction is to dramatize the importance of avoiding a fruitless search for pathology where none exists. Indeed, there is more to disease and illness than is seen in a microscope or in a laboratory.
Why do patients feel more comfortable talking to some doctors and not others? Whereas disclosure does not come easily for many people under normal circumstances, it is even more difficult when they are frightened or in extreme pain. Apprehension over what might be wrong with them often dampens a patient's willingness to reveal certain information. As mentioned in a preceding paragraph, patients often come to their doctors with their own thoughts about what is wrong with them, what might be causing the discomfort, and what might be its implication. Often patients are reluctant to express their ideas for fear of sounding foolish or, perhaps, appearing presumptuous by offering a diagnosis to the doctor. In point of fact, in the interest of establishing better doctor/patient communication, patients should be encouraged to express such thoughts.
Doctor hospitality implies paying attention without intention. Psychological and emotional space must be provided for the patients to fill at their own pace and in their own way. Only when chiropractic physicians are able to recognize their patients as individuals will they be able to recognize them on the other end of the therapeutic continuum.
Self-awareness is the paramount prerequisite for a successful healer. Doctor and patient must share a common bond of humanity in order for true healing to occur. It is a profound experience for any doctor to confront another person's fears of illness; i.e., of pain, death, disfigurement, loneliness or abandonment. Doctors can only find the wherewithal for such empathy within themselves, not some impersonal textbook.
In an article titled, "The Teaching of Interpersonal Skills in U.S. Medical Schools," by Kahn, Cohen & Jason, 1979, most United States medical schools currently require formal communication training, many in Canada are developing such courses, and several institutions in Britain, Australia, and elsewhere are headed in the same direction. How many of our chiropractic colleges are currently headed in that direction; how many of our colleges now offer a separate and specific course in professional communication taught by someone with credentials in that area?
Contemporary chiropractic appears to discourage clinical practices drawing upon such things as institution, fantasy, or emotional accouterments. Deference is often extended to verifiable objective diagnostic data. This penchant for objectivity is compounded by available insurance coverage, malpractice-a-phobia, and the financial incentive. Axiomatically, the larger the practice, the less interpersonal communication between doctor and patient. One patient known to this writer described a typical visit to a local chiropractor. She was ushered into a treatment room by a nurse, told to disrobe and lie face down on the adjusting table. Sine-wave pads were applied by the nurse and the timer set. The nurse left and returned in about eight to ten minutes. The pads were removed and the patient was told that the doctor would be with her in a few minutes. About three to four minutes later, the doctor entered the room and, without saying a word, administered a thumb move in the cervical area, a thoracic thrust, and a couple of low impact thrusts to the sacral area. Upon leaving the room he said, "See you next Tuesday." The patient reported that all she saw of the doctor were his shoes through the headpiece. That was the total extent of the doctor/patient interaction.
As healers, not curers, we must become involved with patient-centered, not illness-centered chiropractic. Eliciting patient attributions increases participation in the process of care. It facilitates patient respect and helps create a therapeutic alliance. Cooperative healing cannot occur in a lopsided doctor/patient relationship. As mentioned at the outset of this article, an individual may be cured, but not healed. Hence, the emphasis here is on healing, not curing. There is far more to the practice of chiropractic than the correction of subluxations. The days of the "bonesetter" are gone. For today's doctor of chiropractic, the welfare of the patient is the supreme law, i.e., "salus aegreti, supreme lex."
Abne Eisenberg, D.C., Ph.D.
Croton on Hudson, New York
Editor's note: As a professor of communication, Dr. Eisenberg is frequently asked to speak at conventions and regional meetings. For further information regarding speaking engagements, you may call (914) 271-4441.