Maximizing value: the importance of re-exams

Other 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 somewhere 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 frustrating 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 average 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 Adherence 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 Daniels 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 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 practitioners 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 scenario, 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 Determinants of Motivation in Goal Pursuit,” Juliano Laran (University of Miami) and Keith Wilcox (Babson College), state: “Goal valence may determine motivation. When the goal is to approach pleasure, the farther people are from the end state the more motivated they are to reach it. When the goal is to avoid pain, the closer people are to the initial state the more motivated they are to avoid it.”

In short, people do the things they do because of what happens to them when they do it – if the behavior led to positive consequences, then the behavior is likely increase. At the end of the day, informed and compliant patients in an open communicative environment usually get good results. In their article “Factors Affecting Therapeutic Compliance: A Review from the Patient’s Perspective,” (Therapeutics and Clinical Risk Management, 2008) authors Jin, Sklar, Oh and Li state: “From the perspective of health-care providers, therapeutic compliance is a major clinical issue for two reasons.” One of which was “non-compliance could have a major effect on treatment outcomes and direct clinical consequences.”

Western health care conditions patients to expect immediate results from treatment, even though there are numerous circumstances with chronic or recurrent concerns where positive outcomes may logically be weeks or months into the future. Also, often positive consequences can occur quickly but they are below levels of conscious perception. The awareness created in a thorough re-exam process demonstrates whether the consequences of treatment are good or bad. Not being aware that anything has resulted from the treatment is essentially the same as extinction.

One of the less evident but impactful outcomes of failing to objectively demonstrate the need for continued treatment is when patients are questioned by friends and family as to the reasons for continuing care independent of symptoms. If the patient cannot justify in their mind the rationale for care, then how can they confidently explain it to someone else? They understandably become embarrassed and start to question the chiropractor’s recommendations. As well, from the friend or family’s perspective, the seeds of distrust of the treating practitioner are sown and this negatively impacts potential for referral. This is not conjecture. People leave care because practitioners fail to reasonably demonstrate the need. Re-exams done properly serve to keep both the doctor and the patient interested in care.

Use as much “show and tell” as you can. Visual aids and feedback materials allows you to showcase results.

Review the initial consultation with the patient, as well as relevant intake questionnaires such as pain scale and vitality biomarkers. When doing your initial examination make sure to notify the patient of positive findings, what they mean and make sure to revisit those same tests and results to demonstrate comparative values. Most of all, make it real so both you and the patient are comfortably in command of the situation and understand what needs to happen moving forward for a life of vitality and exceptional good health.

DR. DOUGLAS POOLEY graduated from the CMCC and has practiced in St. Thomas, Ont., for the past 40+ 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 over 40 years.

This article was originally published in the September 2018 edition of Canadian Chiropractor.