Chapter 7: PATIENT EDUCATION AND MOTIVATION

Chapter 7:
PATIENT EDUCATION AND MOTIVATION



This is Chapter 7 from R. C. Schafer, DC, PhD, FICC's best-selling book:
“Developing A Chiropractic Practice”


The following materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.


All of Dr. Schafer's books are now available on CDs, with all proceeds being donated to chiropractic research.
Please review the complete list of available books
.


Introduction

Professional Services

Establishing a Motivational Climate

The Art of Practice Development

Structured Office Systems

Building Positive Relationships with Children

We described in the last chapter how an individual who is sick, in pain, or worried must be dealt with in a special atmosphere of understanding and consideration to lessen the anxiety involved. When health is lost, the sense of security is lost, and the person is operating on the basic motivational levels of self-preservation and threatened personal safety.

Patient education and motivation are two important solutions to this problem, and these are the primary subjects of this chapter. Professionally, these disciplines begin with and end with the professional services offered. Other major topics addressed include motivational communications, practice development, office systems, and auxiliary techniques.



Introduction

While the doctor's diagnostic and therapeutic skills help to restore hope and relieve some of the patient's emotional stress, a strictly technologic approach is not always enough. A patient's emotions and frame of mind must also be considered as a component of a patient's holistic state of health. The state of rapport between patient and doctor can be just as important as the technical care provided, and this rapport is established on a foundation of sincerity, understanding, kindness, and personalized care.

A doctor has moral obligations and professional responsibilities for each patient's health. Thus, the physician should anticipate possible patient stress by questioning the scope of everyday activities. This questioning and the resulting consideration, however, does not mean to conclude with blunt condemnations. The alert doctor will be aware that typical patients are not interested in the technical aspects of their conditions. They are interested in the removal of pain, discomfort, immobility, and how the condition affects their life-style. Therefore, it is important that the patient's everyday activities, hobbies, work and personal habits be considered along with the clinical aspects of the patient's condition.

Many years of study does not guarantee a doctor a successful practice, nor does an attractive office with a nice location that incorporates modern equipment and pleasant furnishings. These factors only establish an opportunity for success. Every professional needs new patients to replace dismissed and self-dismissed patients.


Professional Services

Comprehensive health-care involves certain professional services to meet certain situations. Basically, all office policies and procedures are designed to support a chiropractic office's four major services:

(1) consultation,
(2) examination,
(3) treatment, and
(4) education.

The initial consultation and history are required to help determine the type of initial examination procedures necessary to isolate the cause or causes of a patient's complaint or complaints. The second consultation follows examination and data evaluation and is held to review the findings with the patient and recommend a treatment program or referral. Ongoing consultations are necessary to receive progress reports from the patient, to counsel the patient against harmful acts, and to provide education toward healthy behavior and performance. The initial examination is necessary to profile a patient's structural and functional status at the time of entry into the practice and to arrive at a diagnosis and prognosis under recommended therapies. Periodic examinations are necessary to monitor the results of recommended therapies, challenge the prognosis, and offer data to objectively confirm a patient's subjective reports. All therapies should be designed to assist the patient in returning to as near a state of health and resistance to disease or normal stress as is possible.

These continuing services are involved in most all cases to some degree, but emphasis is considerably altered depending upon the type of case presented and the type of health care necessary at a particular point in time. For example, the typical office will offer five forms of health care:

(1) emergency care,
(2) acute care,
(3) chronic care,
(4) rehabilitative care, and
(5) prophylactic care.

Typical emergency care is that minimal care necessary to assist the patient (eg, with pain, bleeding) until an appointment can be scheduled for more adequate consultation, examination, and therapy or referral. Acute care usually concerns unanticipated situations such as accidents, strains and sprains, febrile diseases, migraine, colic, or a sudden exacerbation, which, although painful or distressing, leave little permanent damage or predisposition to recurrence. Chronic care is that attention usually necessary in long-standing disorders (eg, degenerative states) where therapy is designed more to check the progress of a condition rather than to reverse a noxious process. Rehabilitative care is rendered in those conditions of either an acute or chronic nature where the disorder has been checked, and therapy is directed to return the patient to that state of health enjoyed previous to the disorder's onset. Prophylactic care is preventive in nature, striving to maintain optimal health and resistance of the patient under the prevailing conditions (eg, degenerative, occupational, environmental, genetic, etc).

From the time patients enter your office until they leave, every procedure should be planned to support the best interests of each patient. Every act should be done unhesitatingly so that you make the impression that you know exactly what to do and how to do it. By so doing, the best interests of your office will be served. This means that all office policies, systems, procedures, records, forms, supplies, equipment, furnishings, etc, are never an end in themselves; they are only vehicles to reach a common goal professional health care.


Initial Consultations

Adult patients come to your office because a degree of faith has been established. If this were not true, they would not be there. Thus, care must be given to first justifying this attitude and then enhancing the confidence level.

The patient should be ushered into the consultation before you arrive. If you are introduced while sitting at your desk, it will appear that you are not busy.

      PREJUDGMENTS

In addition to the clinical needs fulfilled by consultations, the initial consultation is the first direct contact between patient and doctor. Initial impressions have been made through telephone contact with your office, your office environment, and your receptionist's greeting and attitude. Both consciously and subconsciously, this initial consultation is a period where each "sizes up" the other and forms certain convictions from the impressions made.

Even if entering patients may have been under previous chiropractic care, it is not good to assume that they are fully acquainted with the scope of chiropractic health care or the procedures utilized in your office. Who referred the patient to your office can also lead to misleading generalizations. A patient's subjective symptoms and treatment history mean little in arriving at a prognosis unless they are correlated with examination data. Only tactful questioning, induction, and deduction will give you a fairly accurate picture.

      GOALS

Most all subacute and chronic cases evolve through the clinical phases of consultation, examination, and treatment. From both clinical and a human relations standpoint, each phase should establish the need for the next phase. Thus, the first aim of the initial consultation is to gather data and establish rapport.

The second purpose of a formal consultation is to recommend and justify the examination procedures deemed necessary. The basic steps in achieving this goal are: First, a listening period where the patient is allowed an uninterrupted opportunity to tell his story. Second, a following period where the doctor:

(1) reviews the essential facts of the history,
(2) links symptoms with necessary examination procedures,
(3) anticipates major questions that the patient may not have voiced,
(4) offers an overview of the anticipated procedural flow (ie, consultation, examinations, case acceptance or referral, therapies),
(5) explains pertinent office policies and fees relative to the proposed examinations,
(6) describes any possible risks involved in the tests, and
(7) obtains consent to proceed with the examinations recommended. It should also be explained at this time that after the examination data have been evaluated, a full report will be given at the patient's next visit, which will outline what is wrong and what can be done about it.


Subacute and Chronic Cases

Robinson states that about 85% of chiropractic practice consists of subacute or chronic cases. Formal consultations are generally restricted to these types of cases where a lengthy case history is required. While a formal consultation may be by-passed in cases of acute distress, an examination can never be because it directs appropriate therapy. Thus, no patient should be accepted as a patient of a practice until after the examinations have been completed and evaluated.

Some practitioners believe that, when a patient has been under prior treatment and extensive examinations have been made, it should be unnecessary to repeat the tests and subject the patient to duplicated expenses. However, if the patient's disorder has not been relieved, undoubtedly something has been missed. It then appears logical that a greater degree of thoroughness is required that may necessitate reduplication of some tests and the addition of further tests.

A large percentage of patients entering a chiropractic practice involve low back pain complaints. The ACA has developed an easel kit about back pain that makes orientation much easier. This Patient Education Easel Kit (PEEK) is a table-top flip-type presentation featuring attractive illustrations in color (Fig. 7.1). It is designed to help give a comprehensive presentation within a few minutes. While designed originally for in-office use, some doctors use it as a visual-aid during talks before community groups.


Emergency and Acute Cases

Acute and emergency cases usually require an immediate yet thorough examination with simultaneous interrogation. Lengthy case history interrogation, questionnaires, etc, should be reserved for when the patient's acute discomfort has been relieved.

Any case presenting acute pain or discomfort deserves immediate attention for relief. This does not mean that proper examination procedures should be neglected or rushed. It is always better to overexamine and undertreat than underexamine and overtreat. Any treatment given should be qualified as being palliative only and not necessarily that which will be indicated for long term relief or a stabilized correction.

Examination Considerations

Patient interrogation should continue throughout the examination to qualify and substantiate information gathered within the case history. Many doctors conduct a case history systems review while the examinations are in process.

Patients have the right to know what you are going to do to them and why you are going to do it. Inform as you perform. To assure clear motivational communications, tell the patient what you are going to do and what you hope it will reveal. Explain what you are doing again as you do it, and relate it to benefits. As you examine and test, briefly explain:

(1) what you have found that is normal,
(2) what you have found that is abnormal, and
(3) what you hope the procedure will reveal when correlated with other findings. People have a thirst for knowledge when it comes to their own bodies. Almost the same goals can be obtained indirectly, if you wish, by dictating into a recorder in the presence of the patient.

Conditioning the patient beforehand relieves fear of the unknown. Explanation during the procedures assures the patient that you know what you are doing. Postprocedural reinforcement of what you have done thoroughly justifies the procedure. These procedures of dynamic communications hold the patient's attention, make the patient feel as if he is part of the process rather than an object, and deepen the doctor-patient rapport.

"Off-the-cuff" diagnostic judgments should never be offered during your examination, nor should the patient's condition be minimized or inflated. In other words, don't give out clinical information piecemeal that is best delivered within your "Report of Findings." Keep your clinical opinions to yourself until all the facts have been evaluated. It will prevent possible embarrassment if initial impressions cannot be substantiated. However, it is good procedure to make notes of a patient's apprehensions and cover them in detail in your report.

When all tests have been completed, inform the patient that you feel you have all the facts necessary to properly evaluate the disorder(s). State that after you study the findings of the physical, orthopedic, neurologic, and laboratory tests and analyze the films taken, you will have a definite answer for the patient. Advise the patient when you wish him to return for your report, and ask him to present the visit slip at the exit counter and arrange for an appointment.

It is good policy that each patient entering the practice be presented with a packet of pertinent materials at this time.

This packet typically consists of several pieces of literature such as an overview of chiropractic health care, basic office policies, general health tips, an illustration depicting the effects of spinal misalignments, etc.


Reporting Findings

The purpose of this visit is to summarize your examination findings and conclusions, answer the patient's questions, recommend a treatment plan (or referral), explain the "medical necessity," render a qualified prognosis, discuss under what conditions you will accept the case, and obtain informed consent to proceed with therapy.

      QUESTIONS THAT MUST BE ANSWERED

It was described in Chapter Six that the typical patient initially has eight major questions that silently beg to be answered. For review, these are:

  1. What is wrong with me?

  2. What caused it?

  3. What can you do to help?

  4. Will it hurt?

  5. How long will it take to get better?

  6. How much will it cost?

  7. What should I avoid and for how long?

  8. Will there be any lasting effects?

These priority questions should be answered even if the subjects are not brought up by the patient. However, more detailed answers should be given to those that are vocalized by a prospective patient. When these and related questions are answered to the patient's satisfaction, the patient will have faith that you know what you are doing and place his health care in your hands with confidence. If these questions are not answered satisfactorily, the patient's fears will motivate him to seek answers elsewhere.

      STRUCTURING YOUR PRESENTATION

To answer the above questions, the report is usually constructed along these lines:

  1. Discuss each examination's findings, both positive and negative, significant and insignificant, via a systems review that is keyed to the patient's presenting complaints, point by point.

  2. Explain your diagnostic impressions, the disorder's etiology and typical progression, and probable precipitating causes of symptoms.

  3. Briefly explain pertinent spinal anatomy, neural physiology, and chiropractic philosophy.

  4. Outline your recommended treatment plan and check points.

  5. Describe the degree of anticipated discomfort.

  6. Render a qualified prognosis (eg, in percentages).

  7. Explain the office's fee policy, and agree on arrangements.

  8. Thoroughly explain the patient's responsibilities and cooperation necessary (eg, home therapy, exercises, activity restrictions, rest, diet, supplements, etc).

  9. Discuss all anticipated benefits according to typical case histories, national statistics, etc, if your recommendations are followed with sincere cooperation.

  10. Obtain informed consent to proceed with therapy.

To close your presentation in step 10 above, the best question to ask is not if .... but which.... For example, if you have developed rapport in your initial consultation and strengthened it during your examinations, the best way to close is to state something like, "So, what I want you to do to get you on the way to health is to start your treatment program on next Monday or Wednesday. Which is better for you?"

It is usually good to avoid pointing out probable consequences of nontreatment unless the patient is reluctant to follow your recommendations. However, these opinions may be discreetly discussed after the patient is well on the way to recovery.

The presentation should be constructed so that it is well correlated, flows smoothly from point to point, and is stated in terms acceptable to the patient's level of understanding. Patients respect honesty; thus, voice your honest reservations if you have any, but do not belabor the subject of inconclusive findings. The use of charts, diagrams, pictures, textbooks, scaled plastic models, visualizers, and marked x-ray films are quite helpful in showing normals and explaining the progression of the disorder involved.

Keep in mind that people will remember things they are shown much more readily than things they are told. Talk in terms that will enable the patient to "visualize" what you mean. Use analogies to make a point: "It's just like ...." By all means, keep your presentation simple, to the point, and encourage questions. A typical comprehensive presentation need not take longer than 15-20 minutes.

Several authorities agree that the five most common mistakes made during a report are as follows:

  1. The doctor talks too long and explains details too much. If a patient's level of confidence is not high after your initial consultation and examination, the report itself will not save the relationship. Take the time to answer the patient's questions, and get started with therapy as soon as the patient is ready.

  2. The doctor attempts to talk extemporaneously, without the aid of a case resume. This results in rambling, poor coordination, and confusion that most people will notice.

  3. The doctor tends to exaggerate the facts and paint a brighter picture than can logically be expected under the circumstances in an attempt to relieve a patient's fears and gain a reputation of getting people well quickly. However, many disorders require considerable time to heal. When patients are not told that improvement will take time, they may become discouraged.

  4. The doctor fails to differentiate the differences and benefits of palliative therapy, corrective therapy, rehabilitative therapy, and maintenance care. Each has distinct goals. When this is not done, most patients will discontinue therapy on the first signs of improvement.

  5. The doctor makes critical remarks regarding previous case management, failing to realize that this is an obvious indirect criticism of the patient's selection.


Therapeutic Visits

During each visit to the office for therapy, the patient should be questioned about progress (eg, What changes have you noticed since I last saw you?), and the response should be noted in the patient's chart. Then the patient should be examined for signs of progress, and these should be recorded and reported to the patient (eg, There's distinct improvement here!).

Answer any questions the patient might have. Sometimes these questions will come in the form of casual remarks but they should not be taken lightly. Immediately recheck vital signs if pertinent, and carefully re-examine the local area. Only after performing these acts will the patient accept your reassurance. Even minor complaints of transient pain, dizziness, chest pains, etc, should never be dismissed without standard diagnostic re-evaluation and gathering the facts about the circumstances surrounding symptom occurrence.

Fernandez recommends that all points of tenderness should be elicited at each visit so that the patient is fully aware of the need of the visit. He also believes it is important that the patient knows something has been done (eg, perception of an adjustment) and that a change has occurred (eg, less soreness, tissue relaxation, freer movement, warmth, improved weight balance, improved measurements, etc). These help to justify the visit, as far as the patient is concerned.

Result consciousness is what changes a satisfied patient into an enthusiastic patient. Thus, patients must be constantly made aware of the results achieved so far and those anticipated in the future. This firms an appreciation of the benefits received and an expectation of further results. It is essentially your ability to obtain results and impress the patient of the fact that spurs a patient to refer others to you.


Establishing a Motivational Climate

Most of us have found that even personal motivation is difficult at times. Thus, it comes as no surprise that the task of motivating patients on a long-term basis to alter entrenched habits that are destructive to health is sometimes exasperating.

The problem is how to transfer patient agreement in the office to patient agreement in other environments such as daily activities at home, at work, at recreation, and at the dinner table.

Behavioral scientists have expended considerable effort to provide us with greater understanding of the dynamics of motivation that are practical in the doctor-patient relationship. Granted, behaviorists are sometimes accused of developing good theories that don't work in practical situations. However, logic mandates that there is no such thing as a "good" theory that doesn't work. Either the theory is poor or the application is poor. To focus attention on this, we will explore a few basic motivational theories and describe some common observations of application.


Basic Behavioral Frameworks

The core of motivational theory is based on the premise that human energy is the result of internal tensions or needs begging for fulfillment. The goal of most behavior is the reduction of these tensions for the promise of pleasure or the avoidance of pain. Consistent human action (behavior) is thus witnessed as a means of reducing stress by attempting to attain goals that promise to satisfy activated needs. This path-goal framework suggests that patients, as people in general, will behave in a manner that will lead to the attainment of a goal that they value and which they expect they can achieve. Such a framework identifies for the doctor and his assistants three basic criteria that are vital in the motivational process:

  1. Goal availability.   With some disorders, some goals may not be perceived as available to the patient; ie, the prognosis may not indicate complete recovery. This will often require a high degree of psychic adaptability and adjustment on the part of the patient involved.

  2. Perceived effort-reward probability.   How likely is it that a given amount of effort (eg, case management, patient time, finances, personal contribution) will result in the attainment of the patient's priority goals? Does the case management consistently reward the behavior the doctor involved deserves from the patient?

  3. Goal value.   How likely is it that the reward offered within the prognosis provides the means to satisfy the goal valued most by the patient? This factor, goal value, is often the most overlooked factor in patient communications.

It is obvious that the goals (eg, health, strength, locomotion, etc) a patient selects depend on what needs are activated.

Thus, we could conceivably identify an array of anxieties, but such a list would have little practical value in the average office setting. What the typical practitioner and office staff need is a basic framework that offers specific direction to identify, examine, and understand the particular needs of a particular patient that will produce healthy goal-directed behavior. Both the work of Maslow and Herzberg offer such a framework to the doctor even though their work has been primarily employee oriented.

A professional understanding of human nature and why people think and act as they do requires some appreciation of psychologic theory. The reason for this will become more apparent as this chapter progresses.


The Need Hierarchy of Maslow

Put in the simplest terms, Maslow's framework groups all needs into five basic categories:

(2) safety,
(3) social,
(4) self-esteem, and
(5) self-actualization.

Maslow stated that these categories are related to each other in the form of an orderly hierarchy in which one category of needs becomes activated only after its sublevel is relatively satisfied.

The lowest level in the hierarchy, the foundation stone, is physiologic and concerns a person's needs for food, water, and shelter necessary for self-preservation. When these needs become urgent, people don't think about nonskid carpets (safety) or having a new suit recognized (self-esteem). The highest level concerns creativity and self-actualization: the development of latent human potential.


The Dual-Factor Theory of Herzberg

Although not as popular as Maslow's hierarchy of human needs, Herzberg offers a framework that makes two important contributions to a doctor's or assistant's skill in motivating patient attitudes. First, it more explicitly provides the link between a person's needs and performance. Second, the framework provides a model that helps the doctor and assistant apply basic concepts. And third, it identifies two basic factors affecting patient motivation:

  1. The conditions extrinsic to the task at hand.   These would include, for example, office procedures, payment policies, interpersonal relations, insurance benefits, and other "environmental" or "atmospheric" conditions. These factors are important to a satisfactory doctor-patient relationship and have a distinct impact on the optimal results that can be achieved.

  2. The task itself.   This factor presents such questions as: Do the doctor's services and counsel provide a sense of achievement and recognition for that achievement? Are the tasks recommended of primary interest to the patient? Do the tasks provide a challenge that can lead to a sense of accomplishment? Such task conditions are called "motivator factors" by Herzberg because it is their presence or absence that largely determines whether or not individuals will be motivated toward high performance or cooperation.

Conditions extrinsic to the task at hand generally consist of the lower levels of the Maslow need hierarchy such as the physiologic, safety, and social needs. Esteem and self-actualization levels comprise the needs concerning motivator factors.

It is important for doctors and assistants to understand that satisfaction of higher-level needs is a greater spur to typical patient cooperation than satisfaction of lower-level needs in our society. Lower level needs tend to be taken for granted unless threatened. These factors focus attention on two fundamental implications in case management:

  1. The doctor must create an atmosphere in which the patient is able to satisfy lower-level needs so that higher-level needs will seek satisfaction. For instance, the patient is likely to become fixated emotionally at the lower levels during the relationship unless progress is guided emotionally as well as physically.

  2. The doctor must be sure that his instructions are sufficiently challenging and interesting so that they will serve

as a means to the satisfaction of higher-level needs. Otherwise, the patient whose higher-level needs are active will have to look elsewhere to the benefits of "total" health, life enrichment, and the quality of life. The objective of such a program is to design the tasks of case management so that patient performance (cooperation) readily leads to satisfaction of the higher-level needs.

An understanding of patient motivation necessitates a basic understanding of the interaction between patient needs and goals.

This is the path-goal framework, and its importance is being magnified by ever-increasing medicolegal responsibilities (ie, red tape).

Thus far in this section, we have examined the basic formation of the pathgoal framework and have viewed two basic frameworks (Maslow's and Herzberg's) that provide an effective way of looking at patient needs and their relationship to patient cooperation. However, successful application of these theories requires consideration of several areas that are often neglected in practical application.


Basic Application Considerations

The path-goal theory emphasizes the importance of the linkage between motivation, performance, and goal attainment. According to this popular concept, the important variables in the motivation process are:

  1. The availability of the rewards perceived as important by the patient (attainment of pleasure or avoidance of pain). Do the rewards exist in fact? Does prognosis show good promise for attainment? Is the patient convinced?

  2. The probability of achieving these rewards by following the doctor's instructions. Can a high degree of patient cooperation be linked to the rewards the attainment of pleasure or the avoidance of pain?

Most practitioners do a fairly good job in communicating these two areas. Those who are lax in the area of communicating the availability of rewards are characterized by their preoccupation with lower-level needs rather than providing patients with opportunities to satisfy higher-level needs (eg, Herzberg's motivators). Thus, many rewards necessary to insure the fulfillment of the patient's goals do not exist.

Hidden Motives.   The most common fault lies in the doctor's acceptance of the patient's presenting complaint as the "real" complaint that spurred professional attention. As research has adequately established the relationship between goalfulfillment and human performance, practitioners must spend adequate time identifying just exactly what the patient is seeking in terms of health care. This requires some degree of diplomatic interrogation during the initial and especially subsequent office visits when tension has been reduced. Patient needs and related health goals must be isolated if strategic problem solving is to be achieved.

Word Usage.   Diplomatic interrogation also relates to the subject of semantics that was introduced in the last chapter. Ten doctors taken at random will define the simple word health in ten different ways. We can expect no less from lay people. The word health is an abstraction, and a generalization can never be an attainable goal. Both the doctor and the patient must be in agreement as to what the starting point is and what the goal is. This is true for any task that requires cooperation.

The Need for Explicitness.   "Better locomotion in Mrs. Smith's arthritic body" is not a goal. What does "better locomotion" mean? "A 10% increase in the flexion of Mrs. Smith's left knee in 4 weeks" is a goal. There is no question what this means.

Naturally, any goal agreed upon must be within the realm of the doctor's clinical judgment and the patient's needs.

Nevertheless, without specific task goals, neither the patient nor the doctor would know when a task is completed. When a specific task is set and achieved, both doctor and patient are motivated to achieve higher specific goals. When specific task goals are not established, patients self-dismiss and doctors register for another "practice building" seminar.

Communicating Reward Availability.   Aside from the identification of the patient's needs and goals, the alert doctor must spend some time in identifying the rewards available and in determining how best to use them. Eventually, through linking patient goals and probable rewards, the doctor can motivate high levels of confidence and cooperation. Thus, reward identification and usage, as well as goal identification, become prerequisites in the process of motivation. Once rewards are identified, the doctor must be sure that he has conveyed to the patient what rewards are probable in a certain period of time according to the patient's history, the examination findings, the doctor's experience, and the doctor's clinical judgment. The promise of rewards is a necessary condition of motivation.

However, the most important aspect of reward availability in patient relations is not what the doctor says is probable but what the patient perceives and believes will be available.

Defining the Path.   It is also important that the doctor clearly identify the means (path) necessary to achieve the rewards available (ie, the treatment plan). In addition to the clinical procedures conducted at the office, this path may include dietary regimens, therapeutic exercises, and habit alterations that are solely under the control of the patient.

Achievement and Behavior.   Consideration must also be given to the second basic aspect: the probability of achieving rewards through prescribed behavior. What is the linkage between patient cooperation and the attainment of desired results? When a cooperative patient perceives that chances of achieving a particular reward are no better than that of an insincere patient, the doctor may have created a motivational problem. This will most likely result in reduced performance-related behavior because it is not rewarded subjectively or from the doctor or assistants by recognition (self-esteem motivator). Any doctor who feels that he can bring about health by attending to a patient a few minutes once or twice a week when the patient is not cooperating is living in a fantasy world, regardless of his expertise. The attainment of health is not found in a technique, it is found in cooperative goal attainment founded on intelligent actions.

The importance of the relationship between patient goals, the availability of rewards, and the probability of achievement of specific objectives cannot be overemphasized in motivational relationships.


Encouraging Patient Motivation

Maslow has suggested that people tend to aspire to higher and higher levels of need as the lower level needs become fulfilled. Herzberg states that personal achievement is one of the motivators that must be fulfilled if one person desires to motivate another person to higher levels of performance. In addition, research has brought forth two important considerations involved in any form of achievement motivation:
(1) it is important to establish feedback as to how one is doing; and
(2) it is important to establish well-defined, achievable task objectives. In the doctor-patient relationship, especially, these must be mutually agreed upon.

The concepts of the behaviorist concerning the higher-level needs such as personal achievement provide guidelines to action for health-care personnel in the area of patient-cooperation evaluation and feedback. The provision of identifiable task objectives and feedback as to patient performance toward these objectives is lacking in many offices that operate far below their potential (Fig. 7.2). Unfortunately, the doctors involved frequently seek external solutions to these internal problems.

It has been said that the only reason a doctor fails to reach his potential is that the unsuccessful practitioner refuses to do what the successful practitioner is doing. These unfortunates are a benefit to you, however, for they show you what to avoid. Following are some examples of poor application of good theory:

  1. Failure to communicate explicitly.   For example, a patient may communicate to a friend: "Dr. Brown is a fine person, but you never know where you stand. I'm not sure what is expected of me, what I can do to speed recovery, and I only get vague comments as to how I am doing under treatment." Statements by patients similar to this imply a failure of the part of the attending physician. We can readily see that two important elements in the motivational process are missing: (a) well-defined achievable task objectives, and (b) specific feedback as to the progressive accomplishments toward the objectives.

  2. Failure to link task objectives with patient responsibilities.   Too often health practitioners place a low priority on this aspect of communications, which results in the objective never being accomplished because one of the prerequisites to achievement motivation did not exist in the relationship. If a pretentious doctor wants to take all the credit for a patient's recovery, he will also have to take all the blame if the results obtained are not optimal.

  3. Failure to mutually set achievable task objectives with the patient.   This responsibility is avoided by some doctors because they believe this is an infringement upon "the doctor's" prerogatives. Any patient who has a doctor with this set of outdated beliefs is likely to be denied the opportunity to fulfill higher-level needs and adapt to "first aid" benefits only: "When I'm really sick, I go to a real doctor."

When a patient presents an uncooperative attitude, the odds have it that the doctor has failed to recognize the importance of establishing objectives and achieving performance feedback as motivational instruments within case management.


Enriching the Doctor-Patient Relationship

Job enrichment and similar programs, if they are implemented by people who fully understand the purpose and if they are conducted in a well-planned manner, have tremendous potential for solving many of the motivational problems that exist in industry today. These same principles, but on a much less complex level, can be utilized within the doctor-patient relationship with exciting results. Patient motivation through enrichment essentially involves adding meaningful tasks and removing tasks that may cause patient boredom. There is no law that states that you must do the same thing to the same patient in the same way on every visit.

The implementation of a program of this positive nature requires a challenging emphasis in the doctor's role. Some physicians will resist this because they see an usurpation of professional prerogatives rights that exist only in some physicians' minds. They cannot identify with a situation where doctor and patient have entered a partnership toward achieving health goals. The doctor who is inflexible, who cannot see the advantages of such a relationship of shared responsibilities, and who cannot see that such a relationship frees him to tasks that require his specialized attention should alter his thinking. If not, such a doctor knowingly or unknowingly may become a deterrent to the health program, and his contribution will diminish.


Administering to Basic Needs

It should be readily appreciated at this point that positive relations based on a sound understanding of human relations has both clinical and economic benefits. Numerous studies have shown that a patient with a positive mental attitude will heal quicker than one with a negative attitude. On the other hand, a positive mental attitude in the doctor and assistant enhances professional skills. From a practice standpoint, it keeps established patients loyal to the practice and encourages voluntary testimonials that attract new patients to the practice.

      GAINING THE COMPETITIVE EDGE

As undoubtedly there will be equally competent and equally equipped offices in your area, it will be the human relations factors that will differentiate your office from others that offer similar services. Competent health service can be found most anywhere, but competent humanized service is more difficult to find. People will go where their thirst for personalized attention can be satisfied to some degree, if all other factors are equal. This is why some doctors fail to draw sufficiently from their local community while others draw patients from a several hundred mile radius. Without a knowledge of or priority of positive human relations, many doctors and assistants can literally force some patients out of the practice simply by failing to nourish emotional hungers.

We are living in a highly technological-oriented society. We are classified by codes and numbers, our lives appear to be manipulated by computers and indifferent "red tape," and our inner needs for individuality often go begging for recognition and attention. Thus, the average person today is not looking for professional competency, sophisticated technology, or efficient case administration. These factors are taken for granted. The quest is for warmth, reassurance, and personal recognition.

Just as a business that has an abundance of excellent technology can operate in the red, so can a health practice. On the other hand, it is not unusual for a business or a health practice to double its income in a few years once it recognizes the importance of serving people's inner as well as outer needs.

If a patient becomes discouraged, seek some sign of improvement and congratulate the patient on that progress. Discouraged people need hope, support, and reinforcement. Remember, behavior that is rewarded tends to be repeated.

Another important aid is to give the discouraged patient something special to do; eg, an exercise, a diet, a regimen of some sort to get the patient into the act of active participation and expectation. Once the patient cooperates even a little, let them know that you are proud of them: eg, "I'm proud of you for the way you are taking care of yourself. Now I know I can count on you." These are powerful motivators. Gratitude from a doctor for improvement is not an expected thing. Then give special service, and let the patient know it is special service especially for them.

      ANALYZING PATIENT COMPLAINTS

During your initial interview with a patient entering your practice, you may learn that the patient has been switching from tne practice to another for the same condition. This is a clue that emotional needs may be begging for attention. The reasons patients give for changing from doctor to doctor are almost endless, but rarely will they be the real reasons that motivated the self-dismissals. Following are just a few of the more common reasons that patient have great difficulty in openly expressing:

  • "My complaints were belittled and made light of."

  • "I was consistently kept waiting for long periods, as if my time was unimportant. Then I was hurried here and there, and nobody had the time to listen to me."

  • "I couldn't understand what they were doing or why they wanted to do it. When I asked, they talked in highly technical language that confused me. I was treated like a child ...told to obey instructions without explanation."

  • "I was just another case to him. I wasn't a human being. I was the 2 o'clock insurance whiplash."

  • "His assistant played favorites, I wasn't one of them, and I found this insulting."


If we analyze these and scores of similar complaints, we will come to one conclusion. All involve insults to the patient's ego. They all said in unspoken words, "You don't count," "You're not important." Any complaint, however, is serious to the patient involved, and every patient should be provided with concentrated, undivided attention. Within the hospitable environment, people are escorted, not directed. Alert health personnel will take the time to establish a personal rapport with each patient before giving impersonal instructions; and personalized attention will be offered freely, without favoritism. Even if an assistant may be responsible for the primary procedure or therapy on a particular visit, the patient should never leave the office without visiting with the doctor for at least a few moments.


Filling a Potential Communications Gap

Self-preservation is one of our most basic urges. When we feel our health is threatened, we will call on all our energies to return us to as normal a state as is possible. Anyone who will help us has our admiration. Any information that will help us has our appreciation.

      BACKGROUND

When John Smith is ill, he wants to know why he is sick and what you can do about it. After being examined, he wants to know the details of what is wrong and what is right, what he must do and not do to speed recovery, how long it will take, how much it will cost, how he can prevent the disorder from returning, and the answers to many other associated questions. He begs the answers even if he does not ask the questions. A patient wants to understand, for only understanding will ease his anxiety.

He wants a simple explanation, not Latin or Greek "mumbojumbo." He wants his confidence built up, not his intelligence put down.

While the typical patient will crave for the why's and wherefore's of his illness and treatment, he is also timid in asking for answers to his worries and fears. On one hand, the patient wants to know the facts; and on the other hand, he may be afraid to hear the truth. "No news is good news" is not the case because the anxiety goes unsatisfied and becomes a source of chronic stress.

      EXPLAINING

Every patient needs and deserves explanations. When an examination procedure is recommended, he wants to know "Why?" When an abnormal condition is found, he wants to know what it means. When a certain therapy is applied, he wants to know why it will help. He wants to be informed before anything is performed, and he wants this explanation in a simple step-by-step manner that he can understand. Before you do anything, he wants you to explain the features and benefits of each of your proposed actions. He wants you to explain what you are doing and why you are doing it while you are doing it.

He wants you to speak in a straight-forward manner, but tactfully and simply so that he will understand without being frightened or confused. He wants you to appreciate that many things routine to you are not routine to him; what may be obvious to you may not be obvious to him.

      TEACHING

Health care is a learning situation, and you have an advantage. Every patient in your office is a captive student for at least a short time. One well-known chiropractic management consultant states flatly that 98% of dissatisfied patients are patients whom the doctor failed to educate properly.

Time and again it can be shown that the best-informed patient is the most motivated patient; the least-informed patient will be the most uncooperative patient. We should be alert, however, to appreciate that effective communications do not depend on how much is explained to the patient but on how the patient interprets what is said. Again the importance of semantics is underscored. A doctor or assistant may offer a technically correct explanation that is completely misinterpreted by a patient. Patient feedback during discussions is the best method to determine proper interpretation. Inaccurate assumptions result when we "take for granted" that the patient understands because he smiled and nodded.

Offering a simple verbal explanation, however, does not guarantee learning. While we learn through our senses, behavioral scientists tell us that we learn only about 10% by what we hear, a large 85% by what we see, and about 5% through the senses of touch, taste, and smell. Thus, telling is far inferior to showing. Comprehension and recall are also greatly enhanced when we use visual aids such as models, charts, pictures, sketches, graphs, demonstrations, and dramatizations. This depicts the advantage that quality patient literature has on enhancing patient education.

The importance of continual patient education cannot be overemphasized for two major reasons. First, repetition is usually required in the learning process. Second, continual progress within the arts and sciences requires updating and amending procedures and policies that must be communicated to each current patient as well as to each patient new to the practice.

      READING MATERIALS

Printed instructions such as diets and exercises and lists of "Dos and Don'ts" should always be preceded by an oral explanation. Printed guidelines reinforce what has been said and shown in the office. "Take-home" literature tells patients, "We care" by helping them prevent trouble, by helping them understand their health problems and office policies, and by assuring them that important points were not accidentally omitted in the office explanations. Such literature can also add authoritative third-party support to what has been explained (Fig. 7.3). But such forms or tracts themselves should be considered reminders, not recipes.

If time permits, typewritten instructions are better than printed sheets because they say, "This is especially for you." In this regard, Levoy, in The Successful Professional Practice, refers to Les Gibbins' remark that "No girl likes to receive a carbon-copied love letter."

Probably one of the most important forms you have in your office is the preprinted office transaction slip. Aside from its administrative benefits, it itemizes, advertises, and publicizes your full range of services even though a patient may not be utilizing all the services available, thus adding to your prestige and reputation. It also serves as a reminder that all services required for a patient are accomplished, thus helping to assure that each visit will achieve its potential.

      MOTIVATING

It should be remembered that while typical patients want to learn, they have difficulty in learning because they have been conditioned to poor learning habits. Because we are all exposed to so many unimportant words and commercials, we often develop a conditioned response to "turn off." Many people don't hear what's important because they don't listen attentively. Many people don't see what's important because they don't watch attentively. Realizing this as teachers of health, we must stir as many senses in teaching as we can and as often as we can to maintain attention. We must repeat, re-emphasize, paraphrase, and summarize to make an impression. We must build mental pictures through analogies, frequent examples, and comparisons. One well-known DC has a small blackboard in every therapy room where he can give quick "chalk talks" whenever necessary to clarify an idea.

There is no doubt that teaching helps the patient and helps the practice. Patients want to understand and appreciate the features and benefits of the health services you have to offer. They want to learn and to be well informed, and this learning and appreciation cannot be taken for granted. Motivation to learn and to appreciate must be constantly stimulated through repetition of benefits (personal values). Each patient must be shown the personal value for each consultation, examination, therapy, administrative policy, and teaching. If patients are not thoroughly convinced of the personal value from your services, they will only think in terms of time, effort, price, and immediate results.

      ACCESSIBILITY

A procedure helpful to sustaining practice growth is to periodically have the telephone company survey the number of busy signals on office lines during several typical days. As a practice progresses, communications volume increases proportionately. Thus, as your office telephone is the major link with the outside, care must be taken not to antagonize current patients or discourage prospective patients by making it difficult for them to contact your office.


Dialogues That Stimulate Positive Action

Semanticists constantly remind us that what we say is not as important as how it is said, because how it is said determines how people might interpret our meaning. Here are four tips that will help bring this point into practical application:

  1. Generalities don't motivate, specifics do.   "I see that you are feeling better, Mrs. Smith," is a pleasant remark but little else. However, "I see a twinkle in your eye, rosy cheeks, and a lot more smiles now, Mrs. Smith, than I did a few days ago," offers specifics that are distinct reinforcers.

  2. People fear the unknown.   Most people can bear much suffering when they know there will be an end to it. When they don't, even suicide is contemplated. The Communists recognize this when they instigate each "Five-Year Plan" that requires much sacrifice of the common man. Dentists recognize this when they reassure a patient, "Only 5 minutes more in the chair, Mr. Anderson." Nutritionists tell us that most people will hold to successive 10-day diets, but it takes a person with exceptional self-discipline to stay on a diet for an indefinite period. That is also why people get things done when they have a timetable. Fear is diminished once we can somewhat visualize the unknown. It is for this reason that most successful practitioners will outline for a patient a "treatment plan" or "health plan" with an anticipated timetable. Even if it is tentative, it shows a path (means) and a goal (reward).

  3. People want to be needed.   Unless we feel that we are needed by some person, some task, some cause, it is most difficult to justify our existence. "Mrs. Jones, I want you to ...," is almost an order, and nobody likes to be ordered about. "Mrs. Jones, I would like you to ..," is a request, and most people will respond to a tactful request. But, "Mrs. Jones, I need your help to ...," is more than a request, it is a recognition of the importance of the other person. Thus, it's always good policy for yor assistants to use such statements as " I need your help in filling out this form," rather than, "Please fill out this form." I need you are beautiful words, powerful words, motivating words.

  4. People become motivated when they have promise of need fulfillment.   Technical words mean nothing to patients unless they are translated into personal benefits and personal feelings. This is why the wise doctor does not explain the need for dietary supplements in biochemical terms. He will talk in terms that are patient oriented such as: They'll help to "give you more pep," "make you feel younger," "reduce your pain," "sleep better," "heal faster," etc. Regardless of the clinical reasons, all instructions to a patient should be put into words the patient will understand from a personal viewpoint and also from a feeling viewpoint whenever possible. For example, the alert doctor knows that to a tennis player, "It appears that you will be back on the court within 3 weeks" has a lot more meaning to the patient than "This therapy is designed to reduce your epicondylitis." Doctors and assistants can double their motivational power by simply presenting instructions in terms of priority interest of the patient.


Creating a Cooperative Atmosphere

At one time, businessmen told their employees what to do, and they did it. Teachers told their students what to study, and they did it. Doctors told their patients what to do or take, and they did it. Such blind faith and obedience are not characteristic now. Today, businessmen develop participative management programs, students demand some curriculum control, and patients are rapidly developing a need to understand and participate in their health care. Many states have legislated "patients' rights" statutes. This implies cooperation, and cooperation does not mean following directions. It means working together. It means that the whys must be answered. It means that requests must be followed with many descriptive becauses, and these becauses should develop an expectancy of a personal reward, a need fulfilled.

      DEVELOPING A COOPERATIVE SPIRIT

The employer who says, "Do it because it's your job," spurs resistance. "Do it because I need your talent" motivates action plus extra effort. The instructor who says, "Read it because it will be good for you" is missing an opportunity. People don't want to be told "what's good for them." "As knowledge offers power, read it so you'll understand" offers a promise of a personal reward. Anything a doctor or an assistant can say to increase patient cooperation and participation will assist the healing process and help firm the relationship.

When a patient is impressed that he is needed in the process and not just someone to be practiced upon, he becomes actively involved. When instructions are personalized, motivation is increased. When actions are constantly reinforced, motivation is increased even higher and sustained. When whys are answered, the patient is inspired. He cooperates because he wants to, not because he has been told to.

These techniques just mentioned and the many others discussed in this chapter are not psychologic ploys designed to manipulate a patient. They don't use unprofessional "scare" tactics. They are techniques that have been found beneficial in helping patients help themselves. Neither the doctor or assistants are responsible for the patient's illness or disability; thus, the patient must share in the responsibility of getting well. When a patient is motivated to share this responsibility, recovery is much faster, disability time is reduced, and costs are reduced all these benefit the patient.

These steps in motivational communications not only speed positive results, they are also factors that evolve satisfied patients into enthusiastic patients and active centers of referral. The practice using these methods grows because it deserves to grow. It offers exceptional service, and the community will reward it accordingly.

      DEVELOPING A POSITIVE IMAGINATION

From the standpoint of learning situations, the techniques of motivational communications appear to have one common denominator involving the patient's imagination. When a patient can visualize the future, the unknown becomes known to a considerable extent. When a patient can be led to anticipate the future, personal benefits can be visualized. Visualized benefits are motivators. However, this should never mean that promises should be made that cannot or may not be fulfilled.

Besides words and gestures, there are other means to stimulate a patient's imagination towards the goal of health through active cooperation and participation. We previously mentioned the role of seeing vs hearing in learning. Research has also shown that we believe what we see much more than what we hear. Thus, audio-visual tools are excellent adjuncts in motivational communications to enhance belief. Charts, pictures, photographs, diagrams, slides, plastic models, flip charts, films, filmstrips, chalk talks, and pencil sketches are all excellent means to show patients what you mean and how they will benefit.

      DEVELOPING A COMMITMENT

Another excellent means to achieve active patient cooperation and participation is to get the patient to make a personal commitment. A personal commitment helps to establish the volition deep within the personality. This has been shown repeatedly by psychotherapists utilizing Reality Therapy.

How is a personal commitment achieved? Many ways. Informed consent, a medicolegal topic discussed in a future chapter, is a commitment. Initialing a proposed treatment plan or budget plan is a commitment. Getting a patient to do things for you is a commitment. Accepting a filled-out appointment card is a commitment. Responding to the question, "Will you do this?" with a simple "Yes" or "No" is a commitment. Signing a release form is a commitment. Getting a patient to choose between alternatives is a commitment (Monday at 9 or Tuesday at 3?). A commitment is nothing more than a pledge that has strong undertones of honor.

      GRATITUDE IS OFTEN CYCLIC

It also appears to be human nature for many people to forget the pain or discomfort they had at the beginning of therapy. A person in trouble is most appreciative of even small relief. But beyond a certain point, this gratitude wanes rapidly (Fig. 7.4). This cycle will not occur if the doctor constantly reminds the patient of the improvement made and draws a mental picture of what can still be achieved.


Personalizing Patient Care

Ernest Dichter reported on the results of his motivational studies in business and the professions before the Conference of Trans-Canada Medical Plans in 1964. Although this occurred many years ago, his conclusions are still pertinent today:

"In summarizing our findings, what had happened was that while the world was changing very rapidly; while the patient in this world was changing at least at the same pace; while medical equipment, medical knowledge, and drugs were developing at an every increasing rate, the human aspect in the doctor-patient relationship had fallen behind. A psychological lag had taken place...."

Fortunately, the chiropractic profession has not fallen into this psychologic lag as has the allopathic profession. This is probably due to the facts that (1) the "human touch" is an integral part of adjustive chiropractic therapy, and (2) the profession has emphasized concern for the total individual. Unfortunately, there are some indications that our profession as a whole is tending to offer less personalized care than it did 20 years ago when considerably fewer accounts were handled through third-party payers. If this trend continues, a severe problem will be at hand for those who cannot learn from the mistakes of others.

      SPECIAL SERVICES

Patients appreciate services over and above those expected from a professional, and these services need be neither expensive nor time consuming. Special services often take the form of home-therapy equipment or braces available for loan or rental, a lending library, bus schedules, travel tips, a simple beverage while waiting in the reception room, placing a call for a taxi, or some other service that reflects a personalized interest in a patient's welfare.

      SPECIAL INFORMATION

All doctors should maintain accurate and comprehensive clinical and financial records. The need for this in good management and administration has been previously established. But if we wish to serve the total person, more is needed besides cold data to get in harmony with a patient's warm emotional needs. When office records also incorporate personal facts about each patient such as personal interests, hobbies, likes and dislikes, aspirations, etc, you and your assistants are able to speak "in the patient's language." Your power of persuasion will be increased many fold when you know how to explain office procedures and policies in terms of individual patient interests.

Toward this end, many doctors desire a conversational guide to be included with the patient's chart. This guide usually lists facts about a patient's personality, response to compliments, progress as it pertains to the patient's life-style, ability to follow instructions, cooperativeness and its consequences, abnormal degrees of anxiety or depression, major worries, and other personal guidelines.

      SPECIAL ALERTNESS

The more you know about a patient without appearing inquisitive, the more effectively you will be able to communicate with that person. For example, a patient's body language, vocabulary, occupation and position, home (address), organizational memberships, and vehicles (eg, automobile, airplane, sailing vessel) will tell you much. His clothing, posture, hobbies, and educational background offer additional data.

By carefully listening to what a patient talks about in idle onversation, you can become alert to his likes and dislikes, hopes and worries, self-image, pride, and aspirations. You will soon learn how the patient arrives at a decision, how he reacts to a motivational block, and what "special interests" he reveals only to those he feels close to. Knowing such things allows you to truly personalize your approach. You will be able to explain complicated subjects by using analogies meaningful to the patient. You will be able to draw parallels that will ease tensions and develop inspiration.

Careful listening gives you the patient's own key words for proper feedback, so that you communicate that you understand what the patient is feeling and means to say. By paraphrasing the patient's own words, you will be able to instruct the patient in terms he will understand. This act alone will serve to reinforce rapport, enhance the patient's ego in that you "talk the same language," and invite the patient to drop some of his communication defenses because you have proven you were paying close attention and were interested in what he had to say.

This is not a new technique. It has been known by successful educators, salesmen, counselors, and others who have developed a communications expertise. In the June 1965 issue of Reader's Digest, within an article titled, "The Delicate Art of Asking Questions," John K. Langemann stated:

"There is a powerful tool which many professional counselors clinical psychologists, doctors, ministers have learned to use in getting to the bottom of personal problems that people bring to them. Instead of trying to reassemble the facts (who said or did what to whom) or to give specific advice, they listen for and encourage expressions of feeling, however faint or fleeting. Statements that begin 'I feel' or 'I wish' or 'I don't care if ....' are acknowledged by the interviewer, who perhaps repeats their content. Or he may just note, "You feel very strongly about that, don't you?" or "Is that so?" Having such feelings recognized, without judgment or criticism, often has an almost magical effect in making a person open up. The truth comes out, and with it, often self-insight."

The best safeguard against economic decline within individual practices regardless of national trends is the application of scientific knowledge coupled with positive human relations. For further descriptions of positive motivation techniques, communication principles, and related topics, you may wish to refer to another book by this author titled, The Magic of Self-Actualization.


The Art of Practice Development

The motivational level of a patient's esteem for a doctor is the foundation for the doctor-patient relationship and the basis for patient motivation and referrals. The more you tell patients about chiropractic, the more interested and enthusiastic they become. Thus, it's important to carry out a constant patient education program. Some doctors with a high level of vocal selfexpression conduct formal educational seminars, but most practitioners just include patient education as a part of each office visit.


Staff Orientation and Training

The art of practice development and its related techniques should be an integral part of any office orientation and training program. The growth of any practice, as well as its survival, will be determined to a great extent by:

(1) the volume of new patients entering the practice,
(2) the number of established patients under treatment, and
(3) the quantity of dismissed patients returning because of acquired disorders.

The Starting Point.   A typical patient becomes enthusiastic about the health care offered in almost direct proportion to the enthusiasm the doctor and assistants have for the patient as an individual. When you and your staff are diligent in the best interests of the patient, physically and emotionally, the patient will invariably reflect this attitude toward relatives, friends, and coworkers.

Emphasize the Value of Services.   Practices that suffer a long period in getting established are those that fail to instill in each patient the value of the services offered. If this value is not deeply instilled in each assistant, it will not be instilled in patients, and will not, in turn, be transmitted to prospective patients. Your patients cannot express comments about your practice unless they have been impressed about your practice.

Recognize Signs.   Personal recognition, a courteous "thank you," deserved praise, and other acts of positive human relations appear on the surface to be little things. Yet, their lack may be the primary reason for uncooperativeness, failure to refer others to the practice as frequently as in the past, late payments, or cancelled appointments. Human behavior is fairly predictable. People tend to repeat their performance and responses unless their motivational level is changed. Thus, when a cooperative patient becomes uncooperative, look for a breakdown in the relationship somewhere and take corrective action.

Staff Rewards.   The more successful your practice is, the better opportunity your assistants have for career development and advancement. Thus, besides the rewards from loyalty and efficient job performance, your assistants should have strong personal motives to assit you in the development and growth of your practice.


      STAFF ENTHUSIASM

Enthusiasm is contagious, but only if it is natural. Unfortunately, it is not something that can be learned in a classroom.

It is something that is the effect of working each day in a practice, witnessing the results first hand, and becoming absorbed in the professional atmosphere and its contribution to the community. As one who performs an important job in an important field, a chiropractic assistant has the right to be enthusiastic about her occupation and the people she is associated with.

Effective salesmen are enthusiastic salesmen because salesmen have long learned that prospective buyers do not buy from apathetic salesmen. A doctor's assistant in many ways is the doctor's ambassador of good will. Her helpfulness, cheerfulness, and confidence contribute greatly to the image of the office. Her contagious enthusiasm (or apathy) influences each patient she contacts.

The effectiveness of your assistant's enthusiasm, however, should not be limited to the office. At parties, club meetings, showers, and other social affairs, she will invariably be asked where she works. When she replies that she works in a chiropractic office, the next question is usually, "How do you like it?" If she enjoys her work, she can win friends for your practice by expressing her feelings enthusiastically. If she doesn't enjoy her work, she should seek a more rewarding environment within another career.


Developing Referral Centers

Studies have shown that about 94% of all new patients to the typical healthcare office are referred by patients currently undergoing therapy. Many other communications media are helpful, but they do not have the influence of this one source. Thus, it is important to emphasize and re-emphasize this point during training. The doctor and staff of any practice have just so many social contacts, but every patient is a center of influence among relatives, friends, neighbors, acquaintances, and co-workers. No advertising medium can come close to the effectiveness of direct testimonials.

      PRIMARY REFERRAL SOURCES

Many doctors will tell you that most patients who refer are those new to the practice. The reasons given are that at this time the patient is most impressed with new services and their quality, they desire to tell others about the practice to reaffirm their own decision, and symptomatic relief places them on a high level of motivation. This belief is a half-truth.

The other side of the coin is that patients associated with a practice for a long period are often taken for granted and handled in a matter-of-fact manner. Too often, the doctor and assistant radiate enthusiasm and interest in the new patient that is denied to the established patient. That is, "Once they become family, they are no longer treated as special guests."

Thus, for a continued source of referrals and high-level patient motivation, enthusiastic interest and personalized attention must be given to every patient throughout the association with the practice, not just in the early stage of care.

      WHY PATIENTS REFER

It is not difficult to understand that acts promising a pleasurable reward tend to be repeated and acts promising a painful result tend to be avoided. Thus, it's important that each patient who refers a person to your practice quickly receives due recognition and appreciation if you want the act to be repeated.

Even if a "thank you" is made in person, it should be followed up with a personalized note as an extra reinforcement. Your gratitude, however, should never appear as a routine thing (eg, a preprinted card). Be innovative and personal, yet always remain within the realm of good taste. Vary your appreciation with cards, notes, letters, telephone calls, and other means you are comfortable with.

Complimenting a patient for a referral in front of other patients not only adds to the impact of the compliment, it encourages other patients to duplicate the role to receive such recognition.

      COMMUNITY CENTERS OF INFLUENCE

Besides patients of your practice, referrals can be developed from recommendations of many nonpatients. These sources are often referred to as "centers of influence." Such an individual is any person who is respected as an authority, offers counsel, or to whom others turn to for advice. Some examples are the clergy, teachers, attorneys, physical education instructors, coaches, school nurses, allied professionals (eg, dentists, optometrists), health-food store managers, and policemen. Such potential sources should be cultivated socially and placed on your mailing list to receive appropriate, quality literature (Fig. 7.5).

      THE KEY TO GROWTH

Underscore the fact that satisfied patients do not build practices. Moderately successful practices have scores of satisfied patients, but satisfied patients do not sustain the potential growth of any practice. Word-of-mouth practice building is based on turning satisfied patients into enthusiastic informed patients. Enthusiastic patients are primary centers of influence. This fact is the key to sustained growth.

The art of turning satisfied patients into enthusiastic patients is to offer them more than they expect and to subtly, consistently remind them of this fact. When you take the time to give each patient concentrated effort, the patient will be motivated to extend extra effort on your behalf. It appears to be a subconscious urge to return a debt of kindness.

Obviously, waitresses, bell hops, and similar "service" people who give "that extra effort" are those who receive the largest tips. It's human nature to respond in kind.

Many satisfied patients have little knowledge of the scope of chiropractic education and research. When they learn, they become enthusiastic patients. Many satisfied patients have no knowledge of the many postgraduate educational seminars you must attend to keep abreast with the latest technology. When they do, they become enthusiastic patients. Many patients who are satisfied with their personal treatment are unaware of the many types of conditions and disorders handled successfully through chiropractic care. When they become aware, they become enthusiastic and active referral centers.

As enthusiasm is the basis of practice development and the foundation for developing yourself in your career, it is also the spice of life that makes work enjoyable. Thus, it's to your advantage to avoid factors that might sap your energy and enthusiasm. Poor health, association with negative friends, indebtedness, lack of significant goals, unrealistic self-criticism, and poor personal habits are just a few of the enemies of enthusiasm.

You may not feel at peak condition with the first patients in the morning or the last patients in the day. Just as your enthusiasm will enliven a patient, your lack of enthusiasm will depress a patient. Thus, always greet a patient with a spirited attitude. If you feel tired, jog in place for a few moments "to get your adrenaline flowing."

      PRACTICE PHILOSOPHY

The development of a referral practice is not just the application of certain techniques, although many techniques may be described that are helpful. In reality, the development of a referral practice is the result of an office's philosophy. As such, the philosophy enters into and colors all financial, administrative, technical, clinical, and human relations functions of the practice.

When a sound office philosophy is expressed by enthusiastic personnel, the result is automatic and not the implementation of a "technique." When it is automatic, the doctor and assistants will just naturally do and say things that will develop active referral centers. For example, they will:

  1. Impress your patients with the results they have realized. When a patient mentions how well they are feeling, learn to expand on this. It will help the patient learn to vocalize their feelings. If they can testify before you and receive an enthusiastic response, they will be more inclined to testify before others. When patients feel better, they want to tell others but may be timid in such self-expression. You can help the patient overcome this reluctance by being a good sounding board and offering subtle responses that will give the patient some key words that will help him express his feelings in words. The patient will automatically incorporate them into his story when it is repeated.

  2. Take the initiative to suggest chiropractic health care when anyone mentions a sick or disabled friend or relative. When patients tell of a sick friend or relative, give them some appropriate literature on the subject that they can pass along.

    You will be assisting the patient to be a helpful friend. Rest assured that the patient will mention where they received the literature.

  3. Have a system of motivational communications. Use office communications freely such as appointment reminders, thank you cards, follow-up letters, handout literature, and congratulatory notes to reinforce your interest and concern.

  4. Suggest to patients that they mention chiropractic to their friends, relatives, neighbors, and associates when patients are at their peak of enthusiasm.

  5. Patronize patients. Patronize worthy patients who are attorneys, dentists, optometrists, druggists, retailers, insurance agents, contractors, etc, even if you can obtain the same products or services slightly cheaper at another location. If they are willing to spend their money with you, you should spend your money with them. This will firm the doctor-patient relationship and reinforce it each time they see you or one of your assistants at their place of business.

When a patient pays a fee and receives the results anticipated, he is not obligated to refer others to your practice. He has paid for and received a health service. While he is not obliged to refer, he will refer if the human relationship with the practice is positive and enthusiastic. Then he wants to tell others. Again, if he is impressed, he will express.

In addition to evolving procedures and policies, change just for the sake of change can be a motivational factor. Periodic changes in office decor, furniture arrangement, routines, professional attire, and so forth, indicate to many patients the office's attempt to keep "up to date." They also tend to stimulate staff attitudes. Change in itself can often turn apathy into enthusiasm, a rut into a pathway.


Characteristics of a Positive Philosophy

The highly successful doctor is not necessarily an assertive personality. While an abnormally high degree of technical competence is not a requirement, utilizing the competence you have to a maximum is necessary. A sincere desire to serve plus good human relations reinforce and maximize technical competence. Kindness, acceptance, praise, understanding these are the easily applied power tools that turn people "On" when offered freely and honestly or turn people "Off" when they are denied or used as a device to "manipulate" behavior.

      IMPLEMENTATION

When you are expressing a positive philosophy, you will automatically want to know patients better and let them know you better. In turn, they will respond positively because of your sincerity. You will want your patients to know what is happening in your practice eg, new equipment, new procedures, new clinical developments and they will be impressed.

You will want your patients to know what is happening in chiropractic education, chiropractic research, and current public health awareness campaigns and they will be impressed.

You will want to learn what people need, why they need it, when they need it, and how you can help them achieve it because you care. You will be sensitive and responsive, and your patients will know it. You will automatically want to deal with people as individuals on a person-to-person basis, not as numbered cases. Because it's contagious, patients will catch your enthusiasm, spread it to others, and return for reinforcement.

      FOLLOW THROUGH

Once patient motivation is established, it must be constantly fortified just as any hunger must be periodically satisfied.

Motivational reinforcement is as important as a "follow through" is to a professional athlete. While it takes the most energy to get an object moving, it also takes sustained energy to maintain the momentum. We don't live in a vacuum. This requires sustained personalized attention to both new and established patients. When patients become "back-sliders," it is usually the result of poor human relations or a failure to properly follow through with good human relations that were initially established.

      RIGHT ACTION

Even when you have the best intentions possible, your sincerity and kindness may be misinterpreted by a few people. There is a type of personality who has suffered greatly in life. When a person is kind to them, it is almost impossible for them to accept a kindness or a gift without a great deal of suspicion, feeling that there must be some hidden motive behind an act that appears to be sensitive or generous.

Because of past negative experiences, these unfortunate people go through life turning pleasure into pain by their own volition. They have learned to cope with pain, but not with pleasure; with fear, but not with faith. They would rather think the worst always, rather than leave themselves vulnerable to hope, which may prove later to be a traumatic error.

Here you are confronted with a dilemma. If you increase positive human relations, you increase their suspicions. If you decrease positive human relations, you reinforce their suspicions. All that you can do is to do what you think is right action, for it is the individual's programming, conditioning, and habit patterns that are turning your actions and motives into something they are not.


Caveat Emptor

Unscrupulous itinerant hucksters, with their simple solutions to complex problems at weekend seminars, come and go in every profession. Chiropractic is no exception, and only the "once burnt" or exceptionally wise are completely immune from their influence.

Whenever any two personalities come into contact, an influence is made on both even if the contact is only for an instant.

The longer the contact, the more profound the effects --good or bad. That is, what is said or not said and did or not did leave an impression that may be either positive or negative. If the influence is the result of high pressure, action will be short-lived and restrictive. However, if the influence creates a "want to" response, the action will have long-term effects and be relatively unrestrictive.

      UNPROFESSIONAL TACTICS

For a fee, usually a large fee and sometimes on a binding contract, some dilettantes claim to have the answer to practice development and practice management problems. They are extremely adept at appealing to the needs of doctors who do not have the knowledge or experience of professional practice development. Their prey are the immature, the impulsive, and those seeking "instant" success. The typical "pitch" is carefully constructed, highly motivational, and cleverly supported by movies, videotapes, stirring oratory, glossy literature, and an abundance of testimonials to support their claims.

It is easy to become fascinated and caught up in such a highly charged atmosphere, especially when things are not going right and a solution appears to be within reach. However, upon careful analysis when you are away from the direct stimulation, you will find that the appeal is to greed and the method used is fear. Such presentations are a scourge on any profession, but in our free society, people have the legal right to sell most any idea or thing to anybody, regardless of the morality involved, unless it is specifically restricted by law. Thus, every office is bombarded by their mailings and many publications contain their enticing full-page advertisements.

The ethical professional's only defense is careful analysis: Who is this enlightened person (background)? What is he really selling (substance)? Why is he spending productive time trying to sell me (motive), rather than spending his time applying his ideas? Is the program supported by accredited agencies that do not have a conflict of interest (credibility)? Why am I being pressured into pressuring my patients? What will be the long-term effects? Would I want a doctor to treat my mother or father in the manner that is proposed?

People should not be high pressured or "scared" into doing something, even when it may possibly be good for them. Nor should they be forced into a position where they feel they have little choice in the matter. An ethical practitioner will never apply such immoral tactics.

      PERSONALIZED IMPRINTS

It is not recommended that hand-out literature be imprinted with your name and address. If this is done, you stamp the piece as obvious advertising and not a personal service. When it is a gift, you can rest assured that the patient will pass on where they received the literature. Be professional. Those who extol the values of advertising "gimmicks" for doctors are those who are in the business of selling gimmicks.


Structured Office Systems

A sincere practice development program requires that all referrals are accurately and promptly acknowledged and recorded. The minimum data required are:
(1) always know who referred a person to your practice,
(2) how many other people that individual has referred to your practice,
(3) the current rate of total referrals to your practice, and
(4) how this rate compares with past performance and your projections.


Classifications and Codes

Regardless of what type of classification system is used in a practice development program, it must be tailored to meet the requirements of an individual practice. The entire staff must be aware and capable of whatever functions are to be accomplished.

      PATIENT PROCUREMENT EFFORTS

Patient procurement projects can be classified into three major divisions: personal, regular, and irregular efforts.

Personal Efforts.   These concern those essentially individual activities that involve community relations, family life-style and activities, office location and atmosphere, personal areas of influence, personality, character, temperament, reputation, and professionalism.

Regular Efforts.   These involve routine practice activities such as office mailings, congratulatory letters, thank-you notes, directory listings, periodic news releases, new-patient orientation, service club responsibilities, and all the other functions that are implemented on a regular and periodic basis.

Irregular Efforts.   Certain sporadic activities are determined by season, climate, geographical location (eg, urban and rural factors, resort area), and other variables. Activities in these categories should be designed to augment, not replace, regular activities during a predictable "slump" period.

Funding.   Just as a businessman must have funds available for advertising and promotion, a professional requires capital to maintain both regular and irregular practice development programs to let the public know where the office is and what services are offered. Usually, a percentage for such activities is incorporated into the office fee, being as high as 30% for new practices and as low as 5% for well-established practices.

An Auxiliary Office.   When funds are available, a few practitioners augment their income by opening an auxiliary office in a small community 10 35 miles from their main office. Sometimes inexpensive accommodations can be found. As word-of-mouth advertising travels faster in a small town, a productive but limited practice may be developed within a few years. An auxiliary office is usually minimally staffed and equipped only to handle routine cases. More complicated cases requiring more sophisticated equipment are referred to the main office after screening and possibly first aid or palliative therapy.

Another alternative for a recent graduate is to serve as an associate for an established practitioner in a neighboring community. Most management consultants, however, do not recommend either of these alternatives for recent graduates getting started, feeling that they dilute concentrated effort.

      FILING AND FLAGGING TIPS

Color Coding.   In an earlier section on typical filing systems, we described different systems for classifying different types of cases. Color codes can also be used to differentiate various human relations conditions. A certain color can be used to call attention to severely handicapped patients that will require time above that which is typical. Another color may indicate a patient that is hyperkinetic or temperamental, requiring special tactfulness and a minimal waiting time. A color is sometimes used to indicate a patient that has proved to be an excellent source of referrals but requires constant ego gratification. Such codes are limited only by your imagination.

Flags.   Many doctors also find it helpful to flag in different colors charts of new patients, current patients, and former patients. In this system, new patients are those who have never been to your office before or possibly never been to a doctor of chiropractic before. A flag would indicate that a longer orientation time would be necessary. Current patients are those under care at the present time. These patients are considered the primary source of referrals if they become enthusiastic with the services received and results obtained. Former patients are dismissed patients who are returning. These patients may require indoctrination to new procedures and policies established since their last visit.


      THE AD SYSTEM

Another type of classification system is recommended by Levoy. He believes that it allows the doctor to know where and with whom to concentrate special efforts. In this system, patients are rated as A, B, C, and D types.

Type A Patients.   These are well-informed patients who understand and appreciate your services, quickly respond to your suggestions, pay promptly, are enthusiastic sources of referrals, and respond well to suggestions for a health maintenance program after recovery of their original complaints.

Type B Patients.   These are enlightened but not inspired patients who are receptive to persuasion but rarely take the initiative without some diplomatic prodding. Patient education and motivation will often develop such patients into the A category.

Type C Patients.   Moderate understanding and appreciation characterizes these patients. Their apathy and procrastination may be overcome in many instances with persistence, patience, education, and positive human relations. Many may evolve periodically to the B category after considerable effort.

Type D Patients.   These are cost- and time-conscious patients seeking "first aid" rather than a comprehensive therapy and preventive program. As they are not ready for it, much time can be wasted on this type of patient in trying to convince them of the error of their ways. They have little loyalty to any doctor, and the best that can be hoped for is to evolve them to a C category.

Frequently, the above classifications must be subdivided, especially if weaknesses in your application are found. When weak areas are isolated, brain-storm, plan a strategy, set up checkpoints, and re-evaluate your effectiveness periodically.

Levoy recommends that a doctor should emphasize educational efforts on B and C type patients. How long it takes to evolve a patient from one category to another depends upon the office staff's understanding of human nature and their ability to communicate and motivate. Sometimes it will only be a matter of a visit or two; sometimes it may take considerable time.

Every strategy should consider the personalities and motivation involved if it is to be effective, and it must consider harmonious integration with other policies and procedures and not be considered a separate entity in itself.

Referral Acknowledgments

As referrals will undoubtedly be the foundation of your practice development program, an efficient system should be established immediately. Typed letters (composed from a set of form letters) make a much better impression than a printed card, but even these should be individualized so that they will not appear as a form letter.

Studies by the American Optometric Association reveal, surprisingly, that introverted patients have a much higher referral rate than extroverted patients. This can probably be attributed to greater needs for personal recognition rewards if the doctor encourages referrals and shows sincere appreciation for the efforts made.

Patient Recall Systems

Fortunately, health care is evolving from strictly symptomatic treatment to incorporate more preventive care. In recent years, the print and television media have frequently had articles and programs on "holistic health care" and "wellness clinics" that emphasize health education, physical fitness, good nutrition, good health habits, and goal-oriented health maintenance programs. This concept fits well with mainstream chiropractic philosophy.

Many practitioners promote periodic evaluations and adjustments so that a patient may have the advantage of halting an acquired disorder in its early stage, maintaining the stability of a chronic or congenital disorder, or retarding the advancement of a progressive disorder. Many patients on such a program report that they suffer fewer colds, have reduced seasonal allergic reactions, have fewer visceral complaints, heal more rapidly after minor strains and sprains, and generally possess greater vitality and a feeling of "wellness." Providing patients with an opportunity to have their health status periodically re-evaluated is certainly an important aspect of preventive health care.

Dentists have long realized the advantage of periodic check-ups, and the concept has been readily accepted by the general public. To achieve this in a chiropractic practice, all that is needed is an explanation of benefits near the end of a treatment session. Office visits are gradually reduced to monthly, bimonthly, quarterly, and then at 6-month intervals, as the patient's condition requires. Thus, no patient leaves the office without a future appointment and the advice to call the office immediately if they are injured or if adverse symptoms appear.

Once a patient leaves your office with a scheduled appointment, the patient has made a commitment, and you are in control. If a patient leaves your office without a scheduled appointment, the patient has no obligation to return, and you have lost control. When an advanced scheduling system is utilized, there is no need for an elaborate recall system. However, it is good policy to mail or telephone a reminder to reconfirm the appointment of any patient who makes an appointment well in advance.

A family practice in existence for 8 years or more that has emphasized the benefits of prophylactic or maintenance care has little need for sophisticated advertising and public relations programs. These calls fill the vast majority of their appointment schedules.

Even in practices that do not emphasize maintenance care, there will be a large number of patients whom require periodic evaluation after their condition has been stabilized. Typical situations are found in the degenerative-progressive types of disorders; eg, IVD thinning, spondylosis, arthritis, chronic circulatory disorders, etc. When a notation is made within a patient's clinical records concerning examinations and supports, a checkmark should be made at those that require periodic evaluation such as comparative x-ray films, urinalyses, blood profiles, ECGs, braces, stabilizers, shoe lifts, supplements, etc, and the next appointment for re-evaluation should be scheduled immediately.


Building Positive Relationships with Children

When a child's enthusiasm is properly cultivated and stimulated, the child can add much to the education of parents, friends, relatives, and acquaintances regarding the value of chiropractic services. To develop such a state of mind, several points should be considered. Here are some thoughts to enlist in developing better cooperation of both a child patient and the parents:

  • To reduce waiting time, your assistant should try to have everything possible in readiness beforehand.

  • are excluded from the examining and treatment rooms. Few efforts will yield better dividends in health care than gaining the patient's confidence and having the satisfaction of minimizing fears and anxieties, regardless of a patient's age.

  • Many doctors will not treat a nonemergency child patient on the first visit, or only simple prophylactic therapy is given. This is to allow the child a chance to evaluate the office and staff and arrive at the conclusion that there is nothing to worry about. Much can be accomplished during this first visit if nothing more is done but to wean the child away from his fears and apprehensions. Winning confidence is the goal. When the child leaves the office smiling, a good relationship is assured.

      MOTIVATIONAL COMMUNICATIONS

All children love flattery, regardless of their ages. Boys typically like to hear that they are brave, have strong bodies, and have the ability to be an athletic champion if they work at it. Girls generally like to be complimented on their beauty, form, dress, and their potential ability to become wonderful dancers, ballerinas, and attractive to the boys. Flattery helps to solidify the doctor-patient relationship.

Offer companionship to the older child patient that shows you appreciate the patient's intelligence and maturity by liking many of the things he likes and not liking things he doesn't like. Show interest in the child's skills, hobbies, and note these in the patient's chart as a reminder. On the other hand, while relationships should be cordial and friendly, they should not become too familiar. A respectful distance must be maintained or it will stymie respect and require discipline. Children enjoy testing you to see how far they can go. Be friendly in a reserved sort of manner. Children are not adults, thus they must always be understood and handled as children.

Special attention is deeply appreciated by children. Have birth dates recorded, and send a card in rememberance. Some offices send all children associated with the practice a special valentine from the doctor and staff.

High-quality educational material geared to the child's level should be available within the reception room, just as it should be for adult patients and visitors. The ACA Professional Services Department has an excellent assortment of literature available for various age levels.

      MAKING OFFICE VISITS AS ENJOYABLE AS POSSIBLE

Many doctors give each youngster some sort of special gift at the end of the first visit; eg, a balloon, set of crayons, a coloring book, a rubber ball, or an ice cream cone certificate. This special attention endears the child to the office and increases the desire to return. It is not so much the monetary value of the gift that is important as it is the instilling in the child that you feel he is someone special that you like.

When children are frequent visitors to an office, various gadgets are helpful. For instance, lollipops have proved to be standard equipment in many offices as excellent tranquilizers of younger children. If an assortment is available, let the child choose his flavor. It adds to the pleasure and feeling of self-importance. However, never use such a device as a bribe for good conduct; rather, use it as a reward for good conduct.

Toys are helpful in keeping children 2 6 years of age occupied while waiting. Avoid toys with sharp edges, small objects that may be swallowed, things that might break easily, or toys that require running or jumping. Building blocks, coloring books, rubber or stuffed animals, and animated picture books are good choices. A child should be given one toy at a time.

Once he tires of it, he may be given another. Children take their play seriously, but sometimes an assistant may have to point out some possibilities.

A "kiddie corner," equipped with a small table and chairs can be adaptedwithin a 4 X 4-ft space in most any reception room when many children are cared for in the practice. Such a space makes small children feel at home, it minimizes disciplinary problems, and it alerts adult patients in the office that the practice is concerned with the health care of children.

      INSTRUCTIONS

Speak to the child in as much as an adult manner as possible so that you will raise the consciousness of maturity rather than talking "down" to him as a "mere" child. At the same time, try not to exceed the child's maturity level too greatly because you might be misunderstood. Educate by being a good story teller, rather than by giving direct orders or using a paternal attitude. The latter may arouse opposition as the child gets enough of this at home and at school. By putting your instructions in the form of a story, request, or suggestion, the child will more happily comply with what you want.

When special instructions are given to the child to execute outside the office, the instructions should be given directly to the child (if he can comprehend what is wanted) in the presence of a parent. This flatters the ego of the child and develops feelings of self-importance and responsibility.

Any child's question should be answered honestly in terms the child can comprehend. Although unpleasant details can be avoided, a good relationship will be broken if the child learns that he has been lied to or tricked.

Both the doctor and assistant should choose their words carefully when communicating with children who do not understand their meaning. Technical jargon often stirs the imagination to fearful anticipation. It is rarely good policy to discuss the details of techniques or procedures in front of a child, and a doctor should only discuss a child's prognosis with a parent in private. This does not mean that procedures should not be simply explained beforehand to minimize fear of the unknown.

**********************************************************