Consent, risk and videotapes

September 8, 2010
By

Been away for a while. Mainly to think. Think about what it is about the way some people in and outside the chiropractic profession perceive and understand the profession that gives me an itch. And then think some more about why I feel the need to scratch it.

I think this may end up being a long post.

Why I think I have right to scratch it? Don’t know. But I’ll scratch it anyway and do so unapologetically whilst acknowledging that my writing style can be brash and authoritative. In consequence I tell you right now: I don’t know anything for certain, but am comfortable with that, and if I seem to know what I am talking about it is only in the hope that someone turns around and points out that it is wrong. Why do I feel the need to scratch it? Because it itches. It itches and irks me that we can’t seem to just get along and do what is best for the patient, or at least agree that we are all trying to do what we perceive to be- best for the patient.

There are different thinking schools within the chiropractic profession. Some simplify the issue as “straights” and mixers”. I, on the other hand, think that rather than a conscious choice made by individual clinicians based on rationality, the different practice styles emerge as a by-product of affinity of the practitioner’s psychology for a particular style. To be more specific: affinity for what the different practice styles are perceived to represent. Practice “success” for example has different parameters in the two styles. The use of techniques, x-ray procedures and treatment protocols too differ between the two. Of course it is not that black and white, but more a pick’n mix spectrum with Sid Williams at one end and David Byfield on the other. Or at least the perceptions we hold on either men. And I think that our individual affiliation to a practice style on that spectrum (our “choice”) is actually a materialisation of the sum of how we feel about the different definers of chiropractic practice. I, for example, don’t feel I have a great deal of need for X-rays, but I do like MRI scans. I feel that way because lots of my patients (due to the type of practice I have) have already had X-rays and prior investigations. I also feel relatively happy with the fact that if there are no clinical indications of pathology on history taking and examination that I have no further reason to investigate on a screening basis. This means that I may on occasion miss things, but it also means that I accept that in the face of the costs and exposure involved in screening procedures. Other practices may well have more indications or practitioners may well be less comfortable with this position leading them to have practices where X-rays are taken on a more common place basis. I also personally value privacy a great deal and feel the need to be able to have open and frank conversations with my patients. So I work closed-plan. I value privacy as I consider it integral part of the clinical encounter. Some practitioners have different views on this and invest space in a room within the practice where such conversations can be held, whilst generally practising open-plan. I schedule short appointment times, ten minutes apart. 2 minutes more than am NHS GP. I found that my communication style allows for that to be conducive to personable conversation whilst not putting me under such time constraints so not to be able to meet demand. Some people feel that this is too long and conversations should be minimal and do on occasion base that view on the philosophical basis that all a chiropractor should be doing is adjust the subluxation. I feel my role is slightly widened in that I regularly pick up on clinically relevant issues by having these slightly longer but topic-directed conversations. Some people feel that 10 minutes is too short and that I should be spending far more time examining and assessing. I have separate time slots for such events and simply cannot justify the limitations this would put on my diary compared to the potential gain.

In essence; we all way up our comforts and abilities and turn them into practices.

I think problems really emerge, not because of these individual styles, but when a practitioner is trust (hypothetically or in real life) into a style they are not comfortable with or equipped for. I also feel that the arguments emerging on an intra-professional level are largely by-product of such trauma’s.

Some people within the chiropractic profession are not comfortable with uncertainty and feel that all that should be done is that for which there is evidence. I think they need to rethink their suitability as clinicians as it is an inherent component to clinical life to be uncertain. I also think that in the case of chiropractic care, they would do well to remember that research is largely symptom driven (as the outcome measure) but chiropractic care in its theoretical form is not. In its practical form though it certainly is. I believe that some high-90′s percentage of patients presenting to a chiropractor present motivated by pain. The important point however lies in the cross-point between these two worlds; the theoretical and the practical. The patient may very well attend due to pain, but as a chiropractor I do not treat their pain. The patient may very well value my work due to the pain relief they have observed and concluded it to be due to my care, but I provided it to help them heal themselves. “Hypocrite” I hear you say “you provide a guarantee on pain relief”. Yes, ‘t is true. And I do that because I feel I can predictably provide pain-relief as I by-product of my care and because I understand that the patients out there are sick and tired of going round the mill trying stuff and being left out of pocket. I am trying to expose them maybe one more time or for the first time to chiropractic care.

We are all out there trying to practice the version of the profession we are comfortable with and feel we can represent. But one thing I really struggle with: when people take away the basic tenets out of chiropractic because their comfort zone demands them to do so and still call it chiropractic. That, quite frankly, I really do struggle with.

Kind regards,

Stefaan

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  • Ex McStudent

    PS – but there would be less students to swell the coffers to support certain colleges so they need as many undergrads as they can get.

  • Ex McStudent

    ^ Amen

  • http://spinaljoint.com Richard Lanigan

    I think the vast majority of chiropractors would agree with you and recognise the limitations of chiropractic. The problem is the fragile egos of those in charge their need to be right and be able to prove it in relation to a dualism of particular styles of practice which has polarised the profession.
    In their search for the silver bullet technique they promote certain methods rather that the fact that there is a relationship between the function of joints and the nervous system . The skill and experience of the practitioner I suspect is far more important than the named technique.
    Not everyone can master the skills for adjusting spine, unfortunately they dont find that out till they are in the fourth year, by which time they have little choice but to learn how the ultra sound machine works and become medipractors.

    Far better if the colleges weeded out those without the psychomotor skills in first year, rather than focusing on getting rid of those who cant pass biochemistry. If everybody graduated confident in their ability and their colleagues to adjust a spine and the effect that could have, there would be much more harmony within the profession.

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