©Dr. James L. Chestnut B.Ed., MSc., D.C., C.C.W.P.
As chiropractors I am confident that we all believe that every patient deserves to be well and to have a high quality of life. I am also sure that we all understand that health is the single most important resource required for, and single greatest determinant of wellness, prevention, and quality of life. As healthcare practitioners we also share the conviction that every citizen deserves equal and fair access to the resources required to get and stay well and to experience a high quality of life.
As chiropractic care and lifestyle are evidence-based interventions that have been unequivocally shown to result in the expression of greater health and function and quality of life, and to significantly reduce the risk of illness, I believe that every citizen deserves fair and equal access to chiropractic and lifestyle intervention. I believe that a patient or third party paying a doctor of chiropractic a fair fee for care that results in, or has a reasonable evidence-based or evidence-informed expectation to result in, improved health and function and quality of life (a successful patient outcome) represents ethical clinical practice.
I thus define ethical practice success as the fair and ethical exchange between patient and doctor of a fair fee for an actual or reasonably expected successful patient outcome and the fair exchange between doctor and staff of a fair wage for fair work. I contend that both the goal and the right of every ethical chiropractor should be ethical practice success and that ethical practice success is in the mutual best interest of doctor, patient, and staff.
I am not naive. I fully understand that one of the variables that doctors use to define practice success is profit. There is nothing intrinsically immoral or unethical or incongruent about a doctor wanting to be financially successful in practice. The accumulation of a series of fair exchanges of fees for successful patient outcomes naturally and inevitably results in ethical profit. The more ethically profitable exchanges - the more ethical profit. The number of ethically profitable exchanges and the amount of ethical profit form an indissoluble union and are directly correlated. Thus, by definition, the more ethical profit a doctor makes, the more successful health outcomes patients have received, and the more monies that are available to hire and pay staff. Ethical practice success results in a win-win-win relationship among patient-doctor-staff.
Again, I am not naive. I also fully understand that it is very possible for a doctor to make a lot of profit in the absence of fair exchange. I understand it is possible to accumulate profits from unfair exchanges of fees for care that neither results in, nor has a reasonable evidence-based or evidence-informed expectation to result in, patient health outcomes. It is also possible for doctors to unfairly compensate staff in order to increase profits.
This is not an indication that profit or practice success in itself is immoral or unethical. This simply represents unethical profit or unethical financial success. It does not represent unethical practice success because, in my definition, it is not possible to define practice success in the absence of ethical exchange. In my opinion the term unethical practice success is oxymoronic – and a goal striven for and/or achieved only by those who are both immoral and moronic.
There are few things that I find more repugnant than using fear or false promises or false results to take advantage of the sick and this is one of the reasons why I have dedicated my professional life to being a patient advocate and, by natural progression, advocating for patient outcomes to be the foundation of healthcare. As self regulated healthcare professionals who take the Chiropractic Oath we are legally and morally obligated to make successful patient outcomes the top priority of our practices. We are legally and morally obligated to offer care protocols that elicit the best possible outcomes with the least possible amount of expense.
However, this does not mean that it is intrinsically more ethical to provide less care. Providing less care than is required to elicit the best possible outcome is as unethical as providing more care than is required to elicit the best possible outcome. One leaves the patient with less health and quality of life and the other leaves the patient with less money. Both are undesirable and to be honest as a patient I would rather my doctor err on the side of maximizing my health and quality of life than minimizing my expense. I also believe that every patient deserves the right to make their own choice based on the best available information.
At this point it should be self-evident that I contend that the foundation of ethical practice success is successful patient outcomes. Ethical exchange in healthcare is not simply the exchange of an intervention for a fee. Ethical exchange in healthcare is the exchange of an intervention that either results in, or has a reasonable evidence-based or evidence-informed expectation to result in, a successful patient outcome for a fee.
The onus is on the doctor (the payee), to provide evidence to the patient (the payor), of what outcomes are being elicited from the care that is being paid for. Without valid assessment of health and quality of life status prior to and after intervention there is no valid way to determine whether or not such intervention resulted in a successful patient health and quality of life outcome. Without the ability to measure patient outcomes there is no ability to ascertain if there is ethical exchange and thus there is no way to determine if a doctor is practicing ethically. Further, if we do not measure health and quality of life outcomes how can we ever know if we have elicited the best possible outcome; how could we know if we should recommend more or less care?
The entire concept of ethical practice rests upon the ability to validly assess patient health status and elicited health outcomes. No ethical recommendation of frequency or duration of care can be made without such assessments. Do you validly measure the spinal health status of your patients? Do you validly measure their overall health status? Do you validly measure their quality of life status? If not then what is the basis of your care recommendations? When you do a progress examination and report what progress are you measuring and reporting? What is the basis of the frequency and duration of your care recommendations in your initial and progress exams?
If you are telling patients that chiropractic care is worth paying for because it has overall health and quality of life benefits beyond symptom relief do you not have the obligation to provide evidence that these benefits are occurring or that there is a reasonable, evidence-based expectation that they will occur? How can you do this if you don’t measure and record this in your own practice? If you don’t measure actual health benefits and actual quality of life benefits what are you assessing and reporting to patients? Are your reports of findings based on reporting the actual measured and documented benefits your care has elicited or are they about convincing patients to believe that they have received benefits that you have neither measured nor recorded?
Whatever health and quality of life outcomes a doctor suggests to a patient that he or she can reasonably expect to receive in exchange for a fee must be validly assessed and measured before and after each and every recommended interval of care. Basic science can help us explain why chiropractic care elicits results but it can never ascertain whether or not these results are actually being elicited in the patients who are paying for our care. The only thing that can do this is valid pre and post measurements of patient health and quality of life status. We need more documentation of the health outcomes our care is actually eliciting in our practices and we need more practice-based research to inform us about what results we can reasonably expect to elicit in our practices.
I believe that what we all want is ethical practice success. We all want a practice full of fair exchanges. It does not matter if your practice goal is pain relief, and/or recovery of health and function, and/or wellness and prevention, and/or athletic performance. We all share the same goal of an ethically successful practice. We all desire a practiced filled with satisfied patients paying a fair fee in exchange for successful outcomes. Achieving this goal requires care protocols that consistently elicit successful patient outcomes, valid assessments to document those outcomes, and efficient, effective systems to deliver and communicate those outcomes - what I collectively define as clinical excellence. Clinical excellence is the foundation for building and sustaining ethical practice success.
When we can show that patients benefit from our care they will come. They will also refer others to come. When we can show that patients continue to benefit from our continued care they will continue to come. When we can show that patients get worse without our care they will come back. If we cannot show these things then we have not earned the right to ask or expect them to come, to stay, or to come back. The onus is on us and the only way to meet this onus is with clinical excellence.
As many of you know from attending my lectures, attending the Wellness Certification Program modules, or reading my books, I have spent the last 25 years researching and developing the most evidence-based and evidence-informed chiropractic and lifestyle interventions for recovery, wellness, prevention, and performance. I have led the application of the science of epigenetics and the updated physiological model of allostasis to the validation of the health paradigms of chiropractic and lifestyle.
I have spent the last five years pioneering the application of these new scientific models to new protocols of patient assessment that open the window of wellness and prevention and focus on assessing and addressing the causes of symptoms and illness and the sources of recovery, wellness, prevention, and performance.
One of the most frequent requests I have had is to develop systems or protocols for the easy and efficient implementation of the evidence-based and evidence-informed interventions I have compiled. I have spent the last five years developing the Eat Well-Move Well-Think Well® Evidence-Based Chiropractic and Lifestyle Protocols. I believe these protocols represent the highest possible level of clinical excellence and the greatest possible resource for achieving ethical practice success.
These protocols are easy and quick to learn and implement, they will make your exams and reports more efficient while increasing patient compliance, and they will make your care more evidence-based and improve your patient outcomes which always results in more referrals.
For more information on how to implement these protocols and develop the self-sustaining, successful, enjoyable practice you and your patients want call Dr. Rick Baxter at 250.381.2084 ext 2 or CLICK HERE
