GREGORY STEWART, DC 2020-09-01 04:58:22
When bad things happen to good doctors
A patient states that they don’t feel “quite right” following a treatment. They subsequently call to cancel their scheduled follow-up treatment. You wonder if they have experienced a deleterious outcome and the worrisome thoughts integrate your consciousness for several days. At their next presentation, the same patient expresses how well the previous treatment went as a feeling of silent relief sweeps through you. You wonder if this profession is a good fit for your personality type and whether you may have made a regrettable career choice. If you haven’t experienced this yet, you soon will.
Negative thoughts are powerful. Who hasn’t ruminated on a personal conflict, confrontation or bad news? The reason is that negative events have a greater impact on our brains than positive ones. Psychologists refer to this as negative bias (AKA positive-negative asymmetry). Although this emotional imbalance transcends all aspects of life, its impact on a professional can be distressing and devastating.
We spend a great deal of our education dealing with the diagnosis and standards of care for NMSK conditions. Secondly, we learn how to identify those patients who exhibit various yellow and red flags and deal with them accordingly. We then add the complexities of treatment, we evaluate black flags and utilize various stratification tools.
As we go through our careers we are inundated with helpful advice on risk management and how to deal with the unintended consequences of care. We are trained to be cognizant and mindful with ongoing evaluation of the risks and benefits of care throughout the treatment regime. There appears to be a gap in core chiropractic education, continuing education, and regulatory standards. Sometimes things “just happen” regardless of doing everything “right.” In my career, events have unfolded that have given me significant distress and concern. Sooner or later, undesired outcomes, regardless of clinical skill and prudent case management, occur.
Chiropractic, as it is usually in a defensive position, accurately boasts about its safety and continually endeavours to pursue ways in which to deliver care that is safe, and in most cases, much safer than other effective treatments, for the same given condition.
Paradoxically, the procedure of spinal manipulation is not in the public domain, and no chiropractor would recommend that the delivery of care be administered by someone not formally trained and educated in its delivery. Further, the departments of health in the various provinces have included spinal manipulation as a controlled procedure that is restricted to those in chiropractic, medicine, physiotherapy and naturopathy. It is therefore curious as to why we are hesitant to acknowledge the possibility of harm considering the high level of requisite training and restrictive legislation standards.
This may be due to all too frequent attacks from media and our detractors that inhibit our discussion of how to deal appropriately with deleterious events that arise from, or coincidentally, with our care. Certainly other professions experience untoward events, but the consequences to their practice/business, and the profession’s reputation on not put on trial, literally and figuratively.
I once asked a journalist why the media makes little mention of preventable and accidental medical events. (It was estimated that there were ten thousand preventable hospital deaths in Canada yearly and adverse events were common, but largely unacknowledged by media.) At the time, the chiropractic profession was being associated with a recent vascular event.
He stated “medical deaths are like fatal car accidents on a summer long weekend. We expect them. It’s just a news item stating whether it was an above or below average long weekend. In contrast a chiropractic misadventure is akin to someone jumping off an office tower during rush hour. It is news because it is novel and unexpected.”
What other profession would literally have their interventions or its very existence in question from a temporaneous association? Even the best professional liability cannot protect the practitioner from emotional harm of such an event. The impact on health, relationships, respect and practice can exist long after an event is a distant memory to other parties. Confidence can be degraded, doubt about competence can linger, and interprofessional judgement can be isolating. The chiropractic profession is not alone in this. It has been estimated that preventable and accidental misadventures are similarly devastating to medical physicians.
Chiropractors, appropriately, consider themselves as being a member of a caring and compassionate profession. These traits are integral in patient care and are greatly impactful on a patient’s health and wellbeing. There is, unfortunately, a downside. We are in a “relationship- grounded profession” in which we are often involved on a personal level. However, perhaps too involved and to our detriment.
The caring leaves us vulnerable on an emotional level. It is not surprising that a profession that intrudes on personal space, is hands-on, and is supportive of psychosocial nuances, is susceptible to an emotional investment in the patient’s outcome of care. This same personal investment, that is so integral in a compassionate profession, is a double-edged sword when this same care leads to a deleterious outcome.
No chiropractor or healthcare provider of any ilk goes to work to cause harm, but sometimes it “just happens” regardless of skill or experience. Patient co-morbidities will be present influencing the outcome or perhaps psychological issues will be expressed clinically. Although clinical practice guidelines can assist in delivering the standard of care, patient variability is a fact or practice life that no guideline can fully account for.
With spinal manipulation now identified as front line care for spinal care we can shed the ‘alternative’ label. When something has no evidence of effectiveness, there is no level of risk that is deemed acceptable. Comparisons to established therapies, medication, and interventions regarding risk are moot. Unfortunately, risk/benefit ratios require robust evidence of benefit using accepted evaluation tools, including blinding and comparators. We can change the dialogue to being that of direct comparisons, including the number needed to help and the number needed to harm. On a more level playing field we can be less defensive and open regarding our care.
This change has to happen at several levels. Our advocate associations must change the dialogue and boldly face the challenges and career detractors. A defensive position is counter to the reality as well as the relative safety of our care. We should demand that informed consent not just exist in the domain of chiropractic, but rather with all interventions with the potential of harm. The statement: “no effective therapy is safer than chiropractic care” is true and this should be courageously presented to government, stakeholders, and policy makers. This would lessen the guilt and fear of a real or apparent transgression.
Our profession is not alone in this. I have heard many chiropractors state that medical practitioners appear cold and impersonal in their patient interactions. We have to keep in mind that there may be a reason for this and it may develop for self-preserving reasons. We must keep in mind that, like us, they first wish to “do no harm” and have entered a profession with the intent to help others. The medical profession has to deal with dire outcomes, adverse events and accidents at a high frequency. The residency programs expose the doctor to situations in which their emotional vulnerabilities are open and transparent. Unfortunately, the chiropractic programs have almost no exposure to deleterious outcomes and the resultant emotional sequelae.
Studies have shown that surgeons, who are often portrayed as dispassionate and cold, experience suicidal ideation three fold more than the same population cohort. Studies have found that one in sixteen surgeons suffered suicidal ideation over the previous twelve months. [https://www.ncbi.nlm. nih.gov/pubmed/21242446]
Further, studies have demonstrated that ten percent of medical students experience suicidal ideation during professional training. I am unaware of chiropractic students being evaluated for this salient danger. [https://annals. org/aim/article-abstract/742530/burnout- suicidal-ideation-among-u-s-medical- students]
The chiropractic profession has very infrequently utilized mentorship as a priority. All too often, it is positioned as simply a way for chiropractors to facilitate wisdom in care delivery and business practice.
A more practical use may be to exploit the experience of practitioners who have successfully “navigated the waters” of eroded confidence and reputation. This could be as practical as learning how to deal with patients and family who make both fair and unreasonable queries without it necessarily involving a formal complaint or litigation. Your protective association is an excellent resource in many situations but does not have the time to deal with the nighttime restlessness of worry and anxiety. Likewise, our regulators mandate to advise in these matters as it may jeopardize their objectivity if a complaint does come forward.
The profession could benefit from a forum that is confidential, available 24/7, and provides the chiropractor assistance in these matters. It is purely a matter of maturing into a profession that recognizes its shortcomings while concurrently placing that in perspective with the significant service we provide.
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