I have utilized nutrition in my practice for many years and have observed with interest the many different methods used for recommending nutritional therapy. Some work well and others don’t. When evaluating any method, however, I look for the benefits to the doctor’s office and the benefits to the patients. If the method is not beneficial to both, I do not consider using it. Of the dozens of methods I’ve examined, I have found making nutritional recommendations based on bloodwork to be one of the most efficient. Of the many courses available, I feel the best one for chiropractors is taught for the American Chiropractic Association Council on Family Practice (formerly the Council on Diagnosis and Internal Orders).
I will compare the weaknesses of using other methods by themselves, including questionnaires, unusual tests, and subjective tests with highlights of this methodology. Keep in mind that what I feel are weaknesses may not be perceived as a weakness to another doctor. I do not intend to single out the other methods; rather to share what has worked for me and why.
Questionnaires: Treating the Cause Versus Symptoms
A method that seems to have become more popular is the use of a questionnaire to determine a patients’ nutritional needs. Although questionnaires have been around for many years, it has recently surged in popularity so much that some companies charge doctors thousands of dollars simply to know how to use their questionnaire.
The concept behind the questionnaire involves a list of hundreds of questions. These questions address many various organ systems by asking about certain symptoms such as headaches, history of cough, leg cramps, irregular menstrual cycles, painful intercourse, erection difficulties, history of osteoporosis and frequency of bowel movements to name a few. Based on the positive answers and the severity of the problem, the doctor then prescribes what supplements a person should take.
There are several problems with this. One is the doctor is only treating symptoms. When I began to pursue chiropractic as a profession, one aspect that appealed to me was trying to treat the cause of the disease, not just the symptoms. For example, if a patient had a headache, the chiropractor would try to discover why they had a headache. He might try to evaluate if the patient’s eyeglasses were the wrong prescription or if there was any exposure to chemical toxicity. More often than not, the headache was determined to be coming from the neck and an adjustment was delivered. Scientific research has proven the fact that most headaches arise from disorders of the neck.1
On the flip side, it seems that if a patient went to a medical doctor’s office, the doctor would simply prescribe a pill for the headache. If the symptoms (headache) got better, it was good; if it did not get better, then a different pill was prescribed. This is clearly symptomatic treatment. Further, if a chiropractor is recommending a nutritional supplement based solely on symptoms, there is no difference from the example above, except the DC is recommending nutritional supplements instead of pharmaceutical products.
Questionnaires and Bloodwork to Treat Nutritional Deficiencies
I use a questionnaire in my practice and every patient has to fill one out. For example, a patient might indicate he or she has hypertension. Because of the problems listed by the patient, I will be alerted to the fact that I might need to do other tests such as an electrocardiogram (EKG), vascular ultrasound, bloodwork, physical examination and so forth, if the patient so desires. If I find from the bloodwork that the patient has a magnesium and potassium deficiency and the EKG shows an irregularity, I will make recommendations for magnesium and potassium supplementation. However, I am not treating the disease of hypertensionI am treating a nutritional deficiency associated with hypertension.
For comparison, consider a disease that afflicted many people in the days when sailors adventured on the high seas. Scurvy caused sickness and death to ancient sailors and had symptoms of disease such as bleeding gums, hemorrhaging, weakened bones, osteoporosis and death. Scurvy is caused by a vitamin C deficiency. In fact, the C in vitamin C comes from the “c” in citrus.
If a patient came into my office and I were able to determine the person had scurvy, I would simply give vitamin C. I would not be treating the disease; rather, I’d be treating the nutritional deficiency. However, it is likely that within a short period the disease would be gone. I coined the term “scurvy-like” to describe how many of today’s common illnesses are linked to diet.2 In other words, cancer, hypertension, diabetes and others have all been linked to dietary imbalances. Therefore, correcting diet may prevent/reverse the damage associated with these diseases.
If you practice in a state that does not allow a chiropractor to treat disease, you can use a questionnaire to determine what lab tests should be done and then do tests that might uncover nutritional imbalances. You are not treating diseaseyou are documenting the presence of nutritional deficiencies.
The Financial Pros and Cons
Finally, consider the financial practicality of using only a questionnaire. Many DCs have spent thousands of dollars to get one of these fancy questionnaires; yet many do not charge any money to do the evaluation. Some charge nominal fees such as $10 – $30, but the majority of income is derived solely from the sale of supplements. In essence, these DCs have paid thousands of dollars to become a sales representative.
Patient Comprehension of Unusual Tests
Some methods of determining a patient’s nutritional needs involve using unusual tests. There are many different variations on this theme, but urine tension is one that comes to mind. This test suffers from the same drawback as the subluxation. Please do not get me wrong. When it comes to subluxations I am an “above-down and inside-out” sort of person. But, the concept can be difficult for patients to comprehend.
If you went to the best chiropractic educator/evangelist’s office and asked 100 patients what a subluxation is, perhaps only half would be able to tell you. If you ask the same patients what high cholesterol is, not only can they tell you, but they probably can give a list of family relatives who have it. I am not saying this is goodit indicates better education for patients is needed, but it is reality.
Part of the problem with patient comprehension is repetition. How many times does the average patient read about high cholesterol, high blood pressure and osteoporosis while flipping through the magazines in your waiting room? How often do they hear about subluxations in comparison? This is not to say that subluxations are not important, but that most patients do not understand the concept.
Now let’s think again about urine tension. While I am not implying it is not a valid finding, I am asking, “What does it mean to a patient?” If you tell your patients that their urine is more tense or less tense, do they stare at you blankly? You have to spend a lot of time explaining what it means, which is more labor-intensive.
Since patients already understand high cholesterol and other such problems, why not use that understanding to your advantage? If I tell a patient his cholesterol is high, I do not have to do as much explaining as when I tell him his urine is “more tense.”
The Financial Pros and Cons
With unusual tests, we must return to the problem of profitability. I have talked to many doctors who use such tests and I am routinely told they might charge $35 to do an entire panel of such unusual tests. On the other hand, patients are already used to expecting a chemical panel, complete blood count (CBC), thyroid screen and doctor’s office visit to cost around $450 or so. The lab only charges the doctor about $30 – $100 for such a panel, so that means $370 – $400 goes into the office account each time you do an evaluation, not including supplements. Standard bloodwork is profitable and easy for patients to understand.
The Issue of Credibility
I see credibility as an issue with the use of questionnaires, unusual tests and subjective tests such as Contact Reflex Analysis (CRA) and kinesiology. Again, please do not accuse me of implying these tests are not validthat is not my intent. However, I do feel they are not as efficient for both the doctor and patients in terms of meeting their respective goals quickly and easily.
Investigative news programs have increased the public’s skepticism and they come to expect a number of doctors to be part of some scam, conspiracy or cover-up. Keep in mind when you do a test in your office that may be altered with a little effort from the doctor, or you perform a test that is poorly understood, the patient may think there is a trick involved. There is opportunity for the patient to not believe the results. Yet, when a test comes back from an outside lab and says the patient’s blood sugar level is high, it is more objective and reasonable to patients.
Goals of Patients and Doctors
It has been my experience that using outside standard lab tests along with other easily understandable diagnostic tests (such as EKG for the heart, vascular doppler ultrasound for the blood vessels, spirometers for the lungs and so forth) is much more efficient for meeting the goals of the patients and the doctors. The goals of patients are to understand what is wrong with them, be certain they are getting better (or that they are under the care of someone competent enough to know when a treatment program is not working) and feel confident they are investing their hard-earned money in a sound plan of action. Bloodwork and other standardized testing meets these criteria.
The doctor’s goals are to be able to effectively communicate to the patient what is wrong, have a method that will let them know if the plan is working (and if it is not, whether they need to refer), be able to demonstrate quickly and easily to the patient what is wrong, whether they are making progress and to have a program that yields enough income to allow the doctor to continue to help other patients. Again, the bloodwork tests meet these criteria.
Hard Copy Evidence
Machines that produce a hard copy print-out (such as EKGs, bi-directional vascular ultrasound, etc.) increase the doctor’s credibility and profitability. Not only are these tests credible, it is easier to justify the effectiveness of a nutritional therapy program to others when you can show that a glycohemoglobin dropped from 11.4 to 6.1. It is easy to demonstrate that a blood vessel was clogged when it was documented with hard copy evidence (such as the print-out from a bi-directional Doppler) and subsequently is now open after instituting exercise and nutrition. It would be difficult to appear credible saying that a patient is better because the CRA testing indicates they are better.
The Financial Pros and Cons
One of the easiest methods to show patients what works is by testing. It is quick and natural to explain, the majority of patients find it credible and it is profitable. Many chiropractors find it surprising that patients will often pay $1,500 or more in cash for the initial round of tests and interpretations. Of course, not all of this goes straight into the office account. Because this testing involves outside lab expense, perhaps only $1,200 or so actually goes to the doctor. In contrast, it can be difficult to make $1,000 from one patient in a day solely from the sale of supplements as determined by a health questionnaire.
Since it appears to be so efficient to use standardized testing, one may ask why more doctors don’t employ it. If it is simple to explain, get patient compliance and make a profit, then why wouldn’t more doctors do it?
Three Common Fears
Many doctors fear the responsibility of offering standard testing and others have a fear of not being able to learn how to interpret bloodwork. Many doctors I speak with fear having a patient say, “What is a chiropractor doing interpreting blood? You have no business interpreting bloodwork.” In other words, these three fears are common:
- Fear of growing and the unknown.
- Fear of failure.
- Fear of rejection.
Well, get over it. Anything that is not growing is already dead. Other health professions have this skill, plus they want to grow by offering spinal adjusting. Health care is a highly competitive area.
Concerning the fear of not being able to learn about the subject, I have personally found that the instructor really makes a difference. If the instructor teaches purely from academia, it is difficult to make blood interpretation (and other advanced interpretation) come alive. A teacher who has only read a book about using EKGs will not inspire because he or she has never experienced saving someone’s life as a result of using an EKG.
Learning is now much easier than 100 years ago. For one thing, people in general are more educated. Second, libraries, schools and high tech learning resources such as the internet are more readily available. For doctors, there are professional audio and videotapes available that cover topics such as nutritional therapy based on bloodwork, blood sugar imbalances and cardiovascular imbalances.
It is also important to get past the fear of rejection. I have had a few patients reject me, but I’ll bet MDs experience the same amount of rejection and non-compliance. It is a numbers game, as they say. You simply must be OK with rejection. It also helps if you actually care about the patients. If you care about their well-being, the fear of rejection will not stand in your way. You will want them to be healthy and will talk to them out of love. Your concern will bring you to look them in the eyes and say, “Mary, I worry about your health. I believe there are some imbalances that are not being addressed and I should address them. I think we should do the following tests…” If you love the patient, you will risk rejection to help them.
The Rewards for Both Patients and Doctors
It has been my experience that nutritional therapy based on standard testing and outside lab work is profitable and effective for the patient. I have quite a bit of hard copy evidence that I am turning into case studies for journals to document what can be accomplished in a chiropractor’s office.
There are also many rewards to the doctor. One is financial. Another is emotionalit is emotionally rewarding to see a medical doctor take a patient off or reduce his medications because his diabetes is doing so much better. It is emotionally rewarding to see a patient drive 500 miles one way to get to your office based on the results of your work. It is emotionally rewarding to know that a patient will pay you cash, in spite of what insurance might pay, because he values your work.
I know of few things that make this emotional satisfaction possible. Of course, I still love a good adjustment, but I have not found an adjusting technique that will motivate a patient to drive 500 miles. It is my opinion that if someone wants to do nutritional therapy successfully, they need to learn how to use standard tests to know where a patient’s health is, which direction therapy is taking them and when therapy is done.
1.Rothbart, Peter: Findings presented at the first North American Cervicogenic Headache Conference, 1996.
2.Anglen, R. Lindsay: The Middle RoadA Road Less Taken, SM-1, Dynamic Chiropractic, Vol. 15 No. 4, Feb. 10, 1997.