PATIENT CARE VIEWPOINTS Maximizing value We hate re-exams...but love how they build a practice O BY DOUGLAS POOLEY AND KEITH THOMSON ther than those doctors who “really get it,” nobody enjoys doing re-exams. For most of us in chiropractic, the argument is that we check our patients each time they come in, note changes and alter the program of care accordingly. But standards of practice dictate that there must be some-where between 12 and 24 visits, evidence of a comprehensive review of the subjective and objective findings as compared to the initial intake and examination. Purely from the doctor’s perspective, it’s easy to see where this appears to be a waste of both the doctor and patient’s time – but is it really? In our experience the single most frustrat-ing feature of the doctor/patient relationship is the failure of most patients to maintain their prescribed schedule of care. Aside from the few spectacular communicators in the profession, most of us are lucky to have a patient follow an initial short program. We all know that a treatment schedule of 12 visits for an acute injury is by no means unreasonable and in the patient’s best interest. Still, according to recent data on chiropractic utilization, the aver-age patient leaves care at around eight to 10 visits. In other words, when the pain is gone, so is the patient. We believe that scheduling re-examinations at the beginning of the patient encounter and then performing them effectively can extend patient compliance dramatically. According to E. Sabaté in a paper published by the world health organization called Ad-herence to Long-term Therapy is Evidence For Action, Sabaté says: “Worldwide half of all patients choose to not follow their plan of care….” This is a problem across health care, but there are some very important clues as to why this happens, and what can be done to reduce it. In his book Bringing Out The Best In People , Aubrey Dan-iels says: “A basic law of human nature is that behaviour goes where there is reinforcement. Our experience has shown without doubt that effective re-exams serve to do just DR. DOUGLAS POOLEY graduated from the CMCC and has practiced in St. Thomas, Ont., for the past 39 years. He has represented the profession on national and provincial boards and has lectured nationally and internationally. DR. KEITH THOMSON is both a chiropractor and a naturopathic doctor. He is a former president of the College of Chiropractors of Ontario. He has been in practice in Peterborough, Ont., for almost 40 years. www.canadianchiropractor.ca that. The process serves to satisfy basic behavioural needs in people for ‘needing to know the score.’” It is a demonstration of change that allows the patient and the doctor to reasonably assess progress. Due to attitudinal conditioning, for most patients, the over-arching belief is once the pain is gone the problem must be fixed. We as practition-ers know that often this is not the case and a failure to correct underlying structural weaknesses just predisposes the patient to recurrence. This alone is a problem, but by far the bigger concern is the fact that with the recurrence comes the almost inevitable thought that “since the problem came back then chiropractic obviously did not work.” Not only is that factually incorrect, but often serves to alienate the patient from seeking chiropractic care ever again. This is why it is so important to emphasize the root causes of the pain rather than the pain itself and a good re-exam allows you to redirect the mindset towards correcting the more important causal dysfunction. A comprehensive re-exam allows the doctor to bring the patient beyond pain to demonstrate the more subtle changes indicating either that a functional resolve has been achieved, or that there is objectively still a need for more care. This takes the rationale for care from the anecdotal to a fact-based sce-nario, keeping the ultimate goal of correction front and center – it also reinforces the benefits of compliance. In their work, “Pleasure, Pain, and Focus on Initial Vs. End States As De-terminants of Motivation in Goal Pursuit,” Juliano Laran September 2018 Canadian Chiropractor 27
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