Thorough consultation, X-rays, and more steps to a proper treatment plan when rolling out the new patients welcome mat
I can still clearly remember the first new patient I ever saw in “real” practice — that is, not in a chiropractic school clinic setting. I walked into the exam room excited, with adrenaline flowing, ready to roll out my new patients welcome mat, and as soon as I saw the patient, I literally forgot everything that I was ever taught about taking a history and performing an exam.
It was terrifying. I’m sure many of my colleagues had similar experiences early in practice. No matter how well you did in chiropractic school, or how high you scored on board exams, there is no substitution for seeing a real patient, who is most likely in pain.
In order to successfully treat a patient, you must begin with a thorough “Day 1.” Although consultations, examinations and treatments can vary greatly between chiropractors, due to philosophy and technique, we will outline what a successful first visit looks like in my clinic. Following these steps will allow for proper diagnosis and successful treatment of that first nerve-racking patient, and every patient that follows.
The new patients welcome mat consultation
The first thing I always do when I see a new patient is a complete consultation. I will ask a number of questions designed to figure out exactly what may be causing the pain that brought them into the office. These questions follow the OPQRST (Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, and Time) we all learned in school and include:
- How long have you experienced this pain?
- Have you ever had pain like this before?
- Is there any motion or activity that either helps or causes more pain?
- Have you seen any other doctors or tried anything at home to help with the pain?
- Is the pain constant or does it tend to come and go?
- Is the pain worse first thing in the morning or does it get worse as the day goes on?
- Does the pain radiate down your arms or legs?
A good consultation alone usually results in a proper diagnosis 90% of the time.
When rolling out the new patients welcome mat, a complete health history is also part of a solid consultation. This includes whether the patient has issues with any organ systems such as the digestive, respiratory, or renal systems. In addition, I will ask about any previous surgeries or medication that the patient is currently taking.
Finally, I ask about any past traumas, like falls or car accidents. Most of the patients I see have repetitive stress injuries, but I have found that even very minor traumas can cause issues years later.
After the consultation, if I still believe that I can help a patient, I move on to a thorough examination of the spine and nervous system. However, there are times when after taking the history, you absolutely know the patient is in the wrong spot.
I have seen patients come in with blood clots, broken bones and other issues that were out of my ability to treat. If you know you can’t help them at this point, stop and refer them to someone that can. Some of my most satisfied patients (like the patient that I suspected, and was later confirmed, had a blood clot) are the ones I didn’t even treat.
My examination includes range of motion, orthopedic, and neurologic tests. The orthopedic tests are pretty standard and include cervical compression/distraction, shoulder depression, Kemp’s, Straight Leg Raise, Yeoman’s and FABERE, as well as a few others. The neurologic tests include deep tendon reflexes, muscle testing and dermatomes, however, I do not perform all of these on every patient.
I do not limit my examination to only the area of complaint. Meaning if a patient comes in with lower back pain, I do not look at only their lower back, I also examine the neck and mid back. I have found that I get better results when I look at the spine in its entirety instead of just focusing on one area. “It’s all connected” may get a bad rap in some chiropractic circles these days, but rarely do I find that patients only have problems in one region of the spine.
This section may be somewhat controversial, especially with recent chiropractic school graduates.
After the consultation and examination, if necessary, I then move on to take x-rays of the spine. Although many chiropractors are moving away from taking x-rays, I have found that in many cases they are essential for the safety of the patient. Not only do x-rays give me a picture of exactly what your spine looks like, they also keep me from performing any treatment that could be harmful to the patient. Every time I think that I can stop taking x-rays on patients, I find something on x-ray that I never would have suspected.
The most common condition that I find on x-ray that alters my treatment is a spondylolisthesis. Although a spondylolisthesis obviously does not keep me from treating a patient, I have learned over the years that patients with this condition do not respond well to traditional side posture adjusting, but instead do extremely well when being adjusted using a drop piece. If a patient has chronic lower back pain and has not responded well to chiropractic treatment in the past, I often find that they have an undiagnosed spondylolisthesis and the prior chiropractor was adjusting the lower back using side posture. In many cases, their pain level does not improve, and even gets worse. Most patients with a spondylolisthesis do not even know they have one until I review their x-rays with them.
X-rays and unknown medical conditions
In rare cases, X-rays have also allowed me to find severe medical conditions that a patient did not even know they had. In my career, I have discovered cancer in patients three times. In each case, the patient had absolutely no idea, and it allowed me to refer them to oncologists for proper treatment. Had I not taken X-rays, and adjusted these patients, I could have possibly fractured vertebra due to cancer weakening the bone structure.
There is an old saying, “To see is to know, to not see is to guess.” I think that this is true when it comes to X-rays. An X-ray allows me to be sure that there is absolutely nothing that would keep me from treating a patient and allows me to alter my treatment in order to get the best possible outcome for the patient.
Report of findings
The next step I take before treating a patient is explaining to them, in depth, what I have found based on the consultation, exam and X-rays, and how I believe that I can help them. During this time in making new patients welcome I also answer any and all questions from the patient about their diagnosis or treatment are answered. A specific treatment plan is also reviewed with the number of visits and time frame for these visits. The cost of care, and any insurance information, is also covered at this time. I am shocked at how often I hear from patients that other doctors, even other chiropractors, never talked to them at all about their problem, or explained treatment options.
Finally, I give a patient a consent form which outlines any potential risks of chiropractic care, as well as the risk of going without treatment. However, with X-rays and a good consult and exam, we can eliminate almost all of these risk factors. I also explain exactly what the patient should expect before giving them their first adjustment.
Only after I have completed all of these steps do I move onto treating the patient. I firmly believe that skipping any of these steps is not in the best interest of the patient, and that is truly what our entire profession is about. Make your new patients welcome, take a detailed history, perform a thorough exam, take any necessary imaging, and explain your diagnosis and treatment plan before treating a patient. You will get better results and your patients will be happier.
KEVIN WAFER, DC, is a practicing chiropractor in Houston, Texas, and the clinic director at CORE Chiropractic in the Energy Corridor. He can be reached at westhoustonchiropractor.com.