Clinical Decision-making to Facilitate Appropriate Patient Management in Chiropractic Practice: ‘The 3-questions Model’
SOURCE: Chiropractic & Manual Therapies 2012 (Mar 14); 20: 6
Lyndon G Amorin-Woods and Gregory F Parkin-Smith
Murdoch University, School of Chiropractic and Sports Science, South Street, Murdoch, 6150 Perth, Western Australia. L.Woods@murdoch.edu.au
Background: A definitive diagnosis in chiropractic clinical practice is frequently elusive, yet decisions around management are still necessary. Often, a clinical impression is made after the exclusion of serious illness or injury, and care provided within the context of diagnostic uncertainty. Rather than focussing on labelling the condition, the clinician may choose to develop a defendable management plan since the response to treatment often clarifies the diagnosis.
Discussion: This paper explores the concept and elements of defensive problem-solving practice, with a view to developing a model of agile, pragmatic decision-making amenable to real-world application. A theoretical framework that reflects the elements of this approach will be offered in order to validate the potential of a so called ‘3-Questions Model’;
Summary: Clinical decision-making is considered to be a key characteristic of any modern healthcare practitioner. It is, thus, prudent for chiropractors to re-visit the concept of defensible practice with a view to facilitate capable clinical decision-making and competent patient examination skills. In turn, the perception of competence and trustworthiness of chiropractors within the wider healthcare community helps integration of chiropractic services into broader healthcare settings.
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Development of the 3-questions Model
The chiropractic profession, particularly in Western countries, finds itself in a rapidly evolving healthcare landscape, with ‘modernisation’ being a consequence of escalating costs, an aging population, and an ever-diminishing relative resource base [9]. With a view to rationalising resources health system decision-makers are increasingly vigilant about the delivery of safe, evidence-based, cost-effective care, summarised as “the right care at the right time in the right place” [10, 11]. With this imperative in mind, the authors propose three straightforward questions that frame clinical decision-making within the context of diagnostic uncertainty.
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Question 1: What is the likelihood I will delay access to more appropriate care for this patient?
Contemporary chiropractic offers an array of conservative treatments, selected and delivered on the basis of research evidence, tradition, expertise, patient preference, or a combination of all these. Yet, before any treatment can be applied, the practitioner has a duty of care to ensure that the patient will receive the most appropriate care at the right time, which may in fact necessitate referral to another healthcare provider. In other words, the preferences, traditions, and care philosophy of the practitioner are secondary to the needs of the patient, supported by the maxim; ‘first do no harm’ [12, 13]. In short, the practitioner must consider what has gone wrong with the patient as a whole to bring them to this point, and what role the chiropractor may play in their management [12].
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I can’t agree with you more! Identifying where it might be appropriate to consider co-managing the patient with another healthcare practitioner has been a huge part of my practice for over 30 years. Having graduated from LACC, I have always tried to perform a thorough assessment of my patients using blood tests, MRI’s and as many tools as necessary for the good of my patients. Over the years I found back pain that was caused by kidney cancer, or colon cancer and have been able to make the appropriate referral. But, it works in the reverse also. I have been able to diagnose pathology missed by medical physicians that have saved the lives of my patients. Just because they have MD behind their name doesn’t mean they are infallible.
I agree with you Russell. I have been practicing about 7 years now. For me its so hard to try to find others in the “Medical” profession that want to work with me. Any advice you can give?
Thank You
This is a must read for all doctors of chiropractic. This is a topic that can be and I’m afraid is over looked by some practitioners. It’s not only very important to consider “Red Flags” and “Yellow Flags” in evaluating/examining a potential patient but it must be documented. Beyond helping the patient it will become recognized communication by other healthcare practitioners and of course malpractice insurers. If these precautions are not taken and recorded in the health care record no one knows it was done and/or considered. I personally feel that many in medicine don’t understand the role of chiropractors in health care. We need to learn how to communicate with other health care practitioners. If we speak a different language if you will they may not take the time to fully understand. We need to let them know we understand the need to consider “Red” and “Yellow” flags in patient management. I personally know that providing other primary health care providers with UNsolicited patient progress updates in a format they can understand improves relationships other health care providers. One last comment we can no longer broad brush medicine with negative comments. We must be logical in order to be treated logically. Medicine like chiropractic doesn’t have all the answers. Like it or not chiropractic seems at this time to be evolving as a physical medicine speciality. Is it an alternative maybe, but I see it as a credible option for NMS conditions. We must recognize the changes that are taking place and understand our strength and weaknesses. There’s an increasing number of in house chiropractors why? Because patients demand it, it’s effective, it can be controlled and it’s relatively inexpensive. With in house chiropractors the clinic that hired the chiropractor knows what they are getting in the practitioner(philosophy) and has control of the documentation. All chiropractors need to recognize and communicate(document) that they considered other conditions prior to treatment ie. provocative cervical positioning before adjustment and VBI documentation. Let’s don’t give medicine the excuse to ignore us.
When I joined a pain group at a local hospital I had to lecture them as part of my initiation. I discussed topics specifically within the medical profession using medical terms. As I spoke you could see the barriers coming down. Afterward, I was able to express some of my thoughts and views about how chiropractic could be beneficial for the patients when both chiropractic and medicine worked together. That was several years ago and I continue to refer with these doctors. It can happen!