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.

The following is from RC’s best-selling book:
“Human Relations in Health Care”

Human relations as explained in this program involve the understanding of and empathy for the human needs of the sick and disabled. Its importance often runs parallel with the need for technical and professional services.

The chiropractic assistant is not removed from the doctor-patient relationship. She is an integral part of it. To the patient, doctor and assistant are a team. The doctor is judged by his choice of associates as much as he is as an individual. Because of this, this program describes many ways in which an assistant may develop her effectiveness in building patient rapport, respect, and admiration. Yet all explanation has one common denominator: Treat each patient at all times like you would like to be treated under similar circumstances.

Ever since the earliest civilizations, businessmen realized that the success of business depends much on maintaining the good will of their clientele and customers. Even the healing arts realized that skills could be neutralized to a large degree if patient respect and admiration were not nourished. Thus, it is not a new thought that the foundation for human relations in health care is the doctor-patient and staff-patient relationships.

Faith is an unseen ally in any healing process, despite what discipline is used. For centuries, the family doctor was one of the most admired and respected people in the community. The doctor’s reputation was based as much on his “bed-side manner” as it was on his technical knowledge and skill. Unfortunately, with the rapid advance in technology and the increasing complexity in procedures and prescriptions, the medical profession lost much of this respect and admiration when the doctor-patient relationship became more impersonal, cold, mechanically administered. Fortunately, however, this has not been true of chiropractors. Doctors of chiropractic are keenly aware of the importance of positive human relations. They prescribe to a holistic and humanized form of health care.

Few big things but many small things result in positive human relations. The practice must be conducted skillfully, be fair to everyone, and be able to administer counsel, therapy, and fees wisely and justly. Staff must be practical, courteous, and decent. They must know when to be serious and when to have a sense of humor. They must be confidant, adviser, and educator—and frequently much more.

A patient needs and desires sincerity, gentleness, understanding, and affection from the doctor and assistants. The patient senses sincerity in voice, gentleness of touch, an understanding manner, and concerned responses. The doctor of chiropractic recognizes that the sick person resents being treated indifferently: as a nonbeing, case number, or disease entity. Wise health-care providers recognize that they must be scientifically objective yet subjectively empathetic to those who seek care.

Almost every patient that enters the office is fearful to some extent. This fear must be reversed to faith, and it is reversed when the office staff is aware of the necessity of building positive human relations and by being sure that patients’ questions are satisfactorily answered in untechnical language. Most fear is fear of the unknown; questions unanswered are answers unknown.

BASICS

People, especially sick people, warrant alert attention from anybody engaged in offering a service. There should never be shown a lack of interest. Privacy is also important. When the doctor is with a patient, all avoidable interruptions should be prevented. Health service is a private service.

The Human Relations Element

Good human relations is good business, and good human relations is a primary concern of the chiropractic assistant just as it is of the doctor. When the doctor is busy with other patients or duties, it is the assistant who first meets the patient entering the office. First impressions are lasting impressions. Thus the attitude of the assistant is the attitude of the office as far as the patient is concerned.

The first responsibility of the office is the responsibility of the assistant in greeting the patient, welcoming the patient, and in putting the patient at ease. Sick people are apprehensive, nervous, and often extremely sensitive. An assistant’s friendly, professional attitude will help create an atmosphere helpful to the situation.

COMMUNITY RELATIONS AND INVOLVEMENT

It is well, personally and professionally, to build stature and respect by becoming a willing worker in your community. Professional status grows as the community looks to you for aid and advice. For these reasons, doctors of chiropractic encourage their employees to practice good citizenship and become actively involved in their community. However, care should be taken that such involvement does not interfere with one’s work responsibilities.

Organizations such as political groups, charitable organizations, the PTA, the Boy and Girl Scouts, civic organizations, women’s clubs, church groups, and so forth, offer many social and community service benefits. You may, of course, support any cause of your choice, but do not carry your interest or enthusiasm into the office.

Never burden patients or fellow employees for contributions, to sign a petition, to support a political candidate, or to buy raffle tickets unless you have gained permission from the doctor. Your personal opinions on politics and religion should be kept to yourself. Avoid any topic that may be considered controversial.

ON-THE-JOB CONDUCT

All office personnel have a part to play in developing a professional office atmosphere. Health care is a serious business. Patients should not be likened to customers. Professionalism must be conveyed to patients in a subtle manner through office routine, office appearance, and personnel appearance and attitudes. Smoking, gum chewing, eating, reading newspapers and popular magazines, and the like should be confined to a designated area and never done before patients.

Experienced assistants should help orient new assistants to the office’s team approach to patient care. Use the editorial “we” frequently in talking with patients. References to the office as “our office” becomes automatic when the paraprofessional becomes truly team oriented.

Regulation of an employee’s after-hours activities is not the prerogative or intention of the employer-doctor. However, keep in mind that the office has many patients and personnel are frequently observed both within and without the office. Actions of staff help develop the public image of the office. Likewise, the “dating” of patients is usually frowned on as such practice frequently leads to embarrassing if not extremely delicate situations. Office personnel are requested to avoid any personal relationships that might cause patients to feel uncomfortable when returning to the office. Serious indiscretions may be considered cause for dismissal, as would frequent absenteeism, unethical conduct, alcoholism, or drug abuse.

     Personal Conversations

Limit discussions with patients to office matters, and do this in a friendly manner. This does not mean you cannot be a good listener. Conversations with fellow staff members also should be limited to office-related matters during office hours. Habitual chatting reduces the time and opportunities for self-development in your career.

The office telephone is the practice’s primary link with the community. Personal telephone calls during office hours should be brief and limited to the needs of special situations.

     Derogatory Remarks

Another doctor, regardless of which healing branch is involved, should never be criticized in front of a patient even if your doctor employer has expressed certain opinions in private.

     Health Education

All doctors are prohibited from making false claims. Therefore, the chiropractic assistant must be careful not to say anything that could be interpreted as soliciting patients in such a manner. However, an assistant may praise her doctor-employer and/or the office in a professional, dignified manner. It is not unethical for an office to distribute health education information and materials, but a chiropractic assistant must never give specific health advice to a patient. She may, however, relay the doctor’s instructions to a patient and discuss procedures that the doctor wishes explained. Offering professional advice to a patient may subject an assistant to being accused of practicing chiropractic without a license. Likewise, an assistant must never attempt to interpret laboratory reports, diagnostic x-ray films, or any other type of clinical data, though she may be involved in the data-gathering process.

     Personal Attire

What could be more important to the appearance of the office than you? If you look neat, the office will look neater. If you are dressed as a professional, you will help give the office a professional atmosphere.

     Staff Uniforms

Most DCs prefer that their assistants wear white uniforms. However, colored uniforms coordinated with those of the doctor and other personnel are also acceptable. White is commonly used because it symbolizes cleanliness and is associated with the health professions. A white uniform is dignified and commands respect because of the authority it represents. Along with a clean white uniform, it is recommended that the chiropractic assistant groom herself conservatively. It is better to lean to the simple and tailored side during selection than to overdress. In the office, conservatism displays good taste and dignity.

Besides its practical application, a uniform has a decided psychologic effect as patients feel more at ease with an assistant dressed in a uniform —they feel less embarrassment in answering personal questions, in disrobing, and more willing to cooperate.

Uniforms of good quality look better and last longer than the more economical brands, although they may need ironing despite what it says on the label. A good uniform hides undergarments from see through. The nylon uniform is usually avoided as it is commonly associated with beauty parlor attendants or restaurant waitresses. When pastel colors are used for assistant uniforms, the doctor also should consider using the same color for his clinic jacket as it enhances the team concept and indicates concern for harmony, thoroughness, and detail.

     Hands and Nails

As you will be required to contact patients often, hands should always be well washed and the nails should be well kept and trimmed moderately short. Colorless nail polish is preferred to bright red. Never use exotic colors during office hours.

     Hair Styling

A CA’s hairstyle should be neat, conservatively styled, and well brushed. Elaborate or unusual hair styles are out of place in the professional office. Long flowing hair is inconsistent with the professional uniform and offensive to many patients. It should be pinned up during office hours.

     Hosiery

Hose should be of a neutral color with standard mesh. Bare legs, colored hosiery, and unusual weave or embroidery is inappropriate in a professional office, especially with a uniform.

     Shoes

Wear comfortable, well-made shoes (preferably, white) because aching feet and calf muscles will be reflected in your attitude. Shoes should be coordinated with the uniform, comfortable, of conservative style, and may be of the assistant’s personal selection. Excessively soiled or worn shoes should be replaced regardless of age.

     Overgarments

In late spring or early fall when the building temperature is not always consistent, a sweater or light jacket can be coordinated to the basic uniform. Such covering should be kept clean and used only when necessary.

Only jewelry suitable with a uniform should be worn. Use only a reasonable amount of perfume. Bathe or shower daily, and use deodorant as necessary. Breath sprays and mouthwash should be used as needed. Strongly spiced foods and alcoholic beverages should be avoided during the working hours.

     The Professional Image

The assistant’s part in the chain of public relations starts when a patient opens the door to the office. First impressions made on the patient because of office appearance and staff behavior are lasting impressions to be conveyed to others. The power of speech can be to an office’s advantage or disadvantage, depending on how much it is human relations oriented.

A first in-office public relations function is to make the office comfortable, appealing, efficient, and professional in every respect. Another important task is to develop an ability to make friends, gain the confidence of patients quickly, work efficiently, and act professionally. These qualities must become second nature to every member of the staff. A third important public relations effort should be one of public education. To be effective, health education must be centered in the office and expanded in scope to touch every contact of all personnel.

People tend to generalize and stereotype. You represent all chiropractic assistants, the chiropractic profession, and especially your office outside the office, at work, or at play. You have a responsibility not only to your doctor-employer but also to yourself to be a good courier of public relations.

Your every act as a chiropractic assistant, your every word, your every letter, your touch and gentleness, and your every contact with the public should “breathe” prestige, restraint, good manners, and professionalism. This is the image you should want to build and strengthen. It starts in the morning when you arise from sleep; it stops when you go to bed at night.

Thus, to many patients and acquaintances, you represent the office. Since you are building an image every minute of every day, your duty to you and your profession is to build an image of friendliness, sincerity, professional “know how,” and respect. Your image should be one of pride in accepting a responsibility and fulfilling a need. Be recognized as a community-minded citizen who aids in the health and welfare of human beings. It’s a giant step toward a positive self-image and success.

     Essentials

Chiropractic assistants should keep in mind a few essential responsibilities:

···Be aware that you are a professional. Use the highest level of ethics in dealing with patients and the public. Assure that your services are of the highest professional caliber and unquestionable merit. Indicate confidence in every way possible with dignity and tact.

···Be sincerely interested in every patient who enters the office. Also be interested in the physical well-being of America’s citizens and interested in chiropractic as a profession. Do your part to inform and educate the public, thereby advancing the reputation of chiropractic.
Work diligently toward increasing respect for your profession. The public is always conscious of a professional person’s appearance and behavior and the appearance of the office. As a professional, you are constantly under the public’s microscope to be analyzed and critiqued. What you say, what you do, and how you act and react are important. Never let patients, the doctor, or your community lose confidence in you. Practice good public relations in everything you do.

Your personal public relations, the public relations of your office, and national and state chiropractic public relations all have the same objectives: respect, understanding, recognition, and favorable comment. To help you achieve these goals, note the following five rules for dealing with people.

1. Meet new people, and show an interest in them. Learn of their interests, hobbies, likes and dislikes: find out what motivates them. One of the best ways to do this is to become a good listener. By seeking to under-stand others, you will cause others to understand you.

2. Treat people with respect. Be courteous; be understanding; be patient. Acknowledge the rights and opinions of others. Treat all as you would like to be treated, and you then have every right to expect the same in return.

3. Don’t force yourself on people. Whenever possible, try to be professional in your approach. Don’t be “pushy.” Aggressive social behavior does not fit the dignified image of a professional.

4. Truly welcome the stranger. Make the welcome cheerful but to the point. Be friendly and a good listener. Be down to earth and practical in your conversation, and give others a chance to voice their views. Develop the ability to know when to terminate a conversation tactfully and leave.

5. Use a giving rather than a taking approach. Build respect by becoming a contributor of your time, effort, ideas, empathy, and understanding. Don’t become burdensome with your conversations or requests. People should be happy to see you, knowing that the visit will has purpose and meaning. If you accept a job or a project, do it. Don’t expect someone else to carry you.

ETIQUETTE IN THE PROFESSIONAL OFFICE

Office etiquette means observing common courtesies with fellow workers, your doctor-employer, patients, and the public. Etiquette, like ethics, can be summed up in one rule: Treat others in the way you would like them to treat you if the roles were reversed. When in doubt about proper office etiquette, watch the doctor for his example.

Rules of professional etiquette are just as important to know as the rules of professional ethics. For instance, the doctor should always be notified of the visit of another doctor even if an appointment has not been made. The same is true of telephone calls from another doctor.

Two of the most important expressions in our language are please and thank you. They do not and should not be unconscious utterances. Let them come from your heart rather than from habit. Most people crave recognition and appreciation.

Introductions

Learn to introduce people to each other easily. Despite knowing the formal rules, your attitude and interest in people is the most important factor. In general, (1) honor a woman by introducing a man to her; (2)present a young person to an older person; and (3) introduce a patient to the doctor. When it’s necessary to introduce yourself, say something like, “I’m Betty Smith, Dr. Brown’s assistant. May I help you?”

Communication

Use the doctor’s proper title. Never call the doctor by his first name unless you have been requested to do so. Do not call him “Dr. Jim” in front of patients, fellow staff members, or the public. Also, avoid use of the pronoun “he.” Use, “Dr. Brown will be with you soon” rather than “’He will be right out.” Use of the pronoun gives the impression of a casual or careless attitude.

Fees

The doctor’s fees are also an area of sensitive human relations. The wise assistant will always discuss fees and arrangements at the earliest opportunity and arrive at a mutually satisfactory arrangement. Delinquent accounts must be handled with tact and common courtesy.

Respect

Respect the personal property of others; eg, respect office supplies and furnishings and the property of patients. Especially respect people’s feelings. Never be too busy to answer a question with a smile and pleasant response. When help or cooperation is necessary, place your needs in the manner of a request, not an order.

Office etiquette between the assistant and the doctor-employer should be one of mutual respect. Abruptness and impatience is always mirrored back. As the doctor is frequently weighted with many responsibilities and anxieties not burdened on the assistant, a good assistant will avoid adding further burden by being understanding, efficient, loyal, and trustworthy.

In a humanized practice, all patients are treated with respect. Instructions are explained friendly, correspondence is issued promptly, delays are tactfully explained, every patient is offered personalized care and attention, and every patient should feel they are admired and respected as a special person. If not, how would the doctor and assistant build admiration and respect for themselves.

Guard Doctor-Patient Privacy

A patient deserves privacy. Health care is an intimate relationship. Phone conversations, discussions about fees, and case histories must be private and not within the range of others. Voices should not carry from consultation, examination, or therapy rooms. Dressing areas and preparation areas should be private, comfortable, and adequately supplied with clothes hangers and mirrors.

When the doctor is in consultation with a patient, screen calls and keep visitors occupied until he is available. Take notes of all calls for the doctor so that they may be returned later.

Privileged Information

Gossip with patients and coworkers is unmannerly if not unethical. It may be uncomfortable for both you and the inquirer when you must decline to furnish information of a private nature, but confidentiality must be maintained. The law mandates it if a patient is involved.

Discretion

Human relationships should be friendly but not familiar. A health-care office requires close relationships among staff and patients. The subjects discussed, your tone of voice, and your general attitude help in drawing the line between friendliness and familiarity. A respectful and considerate attitude is always in good taste. Flippancy encourages insolence. Professionalism is reflected in quiet good taste, sincere empathy, and a business-like decorum that is hospitable, gracious, and well mannered.

Positive human relations is the result of concern for both impersonal and personal impressions. On the personal side, the chiropractic assistant is cheerful, friendly, and warm. The office is no place to express personal moods. Nor is the office is a good meeting place for friends, relatives or a place to receive personal mail. Keep your personal life separate from office matters. An assistant is hired to help solve the doctor’s problems. He is not there to help solve assistants’ nonhealth problems. Also, never offer to help the doctor on personal matters before he asks you.

The thoughtful assistant treats each patient fairly, with courtesy and without prejudice, regardless of the patient’s social or financial standing in the community. She respects the patient’s privacy, and she respects the doctor’s privacy. Above all, the assistant has a keen desire to serve. She likes people. She has a deep desire to help the sick, the disabled, the aged, the immature. She accepts complaints as suggestions and patient irritability with understanding.

FIRST IMPRESSIONS

As explained, respect and admiration are difficult to develop if the doctor and assistant do not act the way the patient believes a doctor and assistant should act. In many silent ways, both doctor and assistant tell patients about their attitudes by the office and its impressions.

The Physical Office

Neatness and cleanliness is a good example of silent communication. Clean uniforms, clean furnishings and floors, neatly kept magazines, uncluttered desks, spotless equipment, and like concerns for housekeeping communicate to the patient as much as gestures, mannerisms, and tone of voice.

The office environment by itself can do much to add to or subtract from positive human relations. A clean, comfortable, attractive, well-organized office in many ways can do much to communicate to the patient—We care!

Furnishings

Office furnishings should be cheerful and bright, avoiding the “hospital” appearance. This requires carefully selected drapes, carpeting, pictures, planters, and accessories. Good ventilation, air conditioning, comfortable armchairs, adequate lighting, soft music, uncramped space, concern for patient movement from room to room, and well-marked entrances and exits help to establish an environment reflecting concern for people’s needs.

Flowers

Cut flowers will brighten a gloomy winter day. Patients will appreciate the cheerful sight of a bouquet, and the pleasant scent brings smiles to almost everyone’s face. When cut flowers are placed in the office, use a sharp knife to remove an inch from each stem before putting the flowers in water. Do not pinch the stems with your fingers or use scissors. The container should be roomy enough for sufficient water but small enough to provide support for the stems. Be careful to remove all leaves below the water line to prevent rot. Change the water and trim the stems every other day. Cut flowers will fare best if they are in a cool but not drafty spot.

Administration

The alert assistant realizes that every factor within the office environment has a human relations aspect —even routine records. Patients become irritated when records are not neatly maintained and accurate, when financial information is not readily at hand, when statements are confusing, or when reports are delayed.

The concerned assistant realizes that an efficient appointment system is not just for the advantage of the doctor, staff, and practice. It is also a means to respect the patient’s time. It reduces waiting time to a minimum, anticipates emergencies so not to disrupt the entire schedule, allows for different times for different procedures, and is efficient. Yet, it is humanized.

Helping the Doctor During New Employee Indoctrination

As human relations involves staff and patients, it also involves the relationship of staff among itself. This is especially true when new employees are added to the staff. Breaking-in a new member of the staff is not a task that should be treated without advance thought by all concerned. Once a person has been selected for employment, the training period is very important so that a humanized approach will be incorporated in training. The new person should be imbued with the idea that people learn by doing, not by endless listening, talking, and demonstrating. It is one thing to tell the person how to perform a given task; it is another to have the trainee successfully demonstrate that she can do the job assigned.

Training a new person at one job at a time is another good rule. A new employee may be “snowed” if a variety of tasks is thrown at her in too short of a time. Also make it a point during training to reserve some time after each training session to review and clarify any problem situations that are bound to arise.

Helping the Doctor During New Patient Indoctrination

When the doctor answers a patient’s questions concerning the patient’s condition, he not only relieves fear, he builds faith in the patient that he knows what is wrong (diagnosis), what to do about it (treatment), and creates added respect and admiration when he tells that patient how the patient can prevent recurrence and maintain maximum resistance.

The doctor is aware that the typical patient initially has six basic questions that must be answered: (1) What is wrong with me? (2) What caused it? (3) What can you do to help? (4) What can I do to help? (5) How long will it take to get better? (6) How much will it cost? The doctor’s consultation and examination will be aimed at finding the answers to these questions. When the doctor answers these and associated questions, the patient has faith that the doctor knows what he is doing, and the patient places his health care in the doctor’s hands with confidence. If these questions are not satisfactorily answered, the patient’s fear will motivate him to seek the answers elsewhere. Thus, CAs should be alert to a patient’s comment that one or more of these questions has not been answered to the patient’s satisfaction. If recognized, bring this immediately to the attention of the doctor so that he can offer appropriate answers.

Direct consultation is but one medium the humanized practice uses to communicate to the patient. Patient information booklets, health tracts, reception room literature, written patient instructions that re-emphasize verbal instructions, printed office policies, as well as charts and illustrations and audiovisual programs are also effective auxiliary means toward patient education and motivation.

BASIC PSYCHODYNAMICS IN PROFESSIONAL HUMAN RELATIONS

The patient who is sick is under stress. One role of the assistant is to be sure she does nothing to add to this stress. The sick person needs a friend, an understanding friend. A friend who is cheerful, polite, well mannered, and poised. A friend who is efficient, calm in emergencies, devoted to her work, and soft spoken. A friend who is sympathetic, understanding, helpful, alert, and utterly dependable. Patients will love such an assistant and be devoted to her as she will be to them. This is one reason the career as a chiropractic assistant is so rewarding.

As human beings, we are all impelled by desires, fears, hopes, doubts, and emotional highs and lows, as well as selfish and self-centered thoughts. Recognizing such thoughts and motives early helps us control their intensity, duration, and expression when with patients. Nobody is perfect. All humans have potential contradictory emotions: some are constructive, helpful, and cheerful; others are unhappy, hostile, and revengeful. It is not unusual to have these tendencies conflict with one another, but wisdom helps us recognize them and make appropriate restraints because patients in discomfort are not interested in our feeling. They are only interested in their own feelings. The role of the professional in the office is to serve the needs of the patients.

Applied Psychology

The doctor’s image and reputation are affected each time an assistant contacts a visitor to the office. By her attitude, the assistant can build the practice or diminish its effectiveness. In her hands, she can build human relations by creating an atmosphere of good will and efficiency or create negative relations by being nervous, overtalkative, aggressive, snobbish, or boorish. The chiropractic assistant is the doctor’s ambassador of good will: his primary public-relations representative.

When you stub your toe, you suffer a musculoskeletal injury. But it is more than this. You hurt all over. The injury has its effects throughout your total being: physically and mentally. Because of the pain, all systems will be affected. Even your digestion may be affected. You undoubtedly will feel anger, which may affect your entire nervous, endocrine, and other systems. More is involved than just a stubbed toe.

A patient who is sick, disabled, or worried must be handled with special understanding of the nature and scope of illness or disability. When health is lost, security is threatened. We need sympathetic attention. When our security is threatened, we automatically become hypersensitive. Normal lighting may bother our eyes, normal odors may become offensive, and normal sounds may seem to be loud noises. Nothing tastes good. It is not unusual to develop hypochondriac symptoms and acquire new phobias. When we become sick, our entire being is affected, not just an isolated part.

Sick people have many fears. Fears of prolonged pain or disability, fears for the family’s security, fears of income loss and of doctor bills. The chiropractic assistant must be empathetic with these feelings and understand why patients are sometimes irritable and grouchy. For some obscure reason, a patient may hide these symptoms from the doctor, yet openly vent them to or on an assistant.

When a patient is sick, he recognizes only one sick person in the world —himself. He seeks personal attention, unhurried attention, immediate attention. Although he may be pessimistic, he expects all around him to be optimistic. While he may be hypersensitive, he will expect others to be insensitive to curt remarks, rude manners, and complaints. After all, he believes, he is sick and has the right to let the world know it. The wise chiropractic assistant will understand this.

Every practice will have a few problem patients, and every practice will have many patients with a few problems. Some patients will be habitually late yet complain on having to wait. Some patients will repeatedly disobey the doctor’s instructions and complain of the slowness of their recovery. Most of these complaints will be to the assistant and sometimes in front of other patients. In such instances, the assistant’s tact and grasp of psychology will be measured. Turning patients’ complaints to renewed confidence, good will, and friendship is an art that develops with experience, a basic understanding of human nature, and a firm service philosophy.

Body Language

Body language is essentially nonverbal communication as expressed in body movements, gestures, and mannerisms. Behavior of the hands, fingers, arms, legs, feet, and head offer frequent signs that reflect a patient’s inner feelings. Facial expressions, eye movements, voice tone, and inflection, as well as standing, sitting, and walking postures offer other signs.

Conscious or unconscious behavior in motion is an outward expression of inner attitude. Observation informs us that there is often an incongruity between verbal language and body language, between what a patient’s words reveal and what his subtle actions are really communicating.

Body language offers both positive and negative signals to the careful observer. When an assistant sees negative groups of signs, it’s her clue to try to remedy the situation. The patient is unconsciously trying to communicate something felt but for some reason cannot be put into words. For instance, if you say something that evokes a sign of confusion or doubt, it is your clue to offer more clarity or evidence.

When an assistant sees positive groups of signs, this tells her that the relationship is positive. If you make a statement that brings out a sign of acceptance and agreement, it is your clue that your words are not meeting indifference or rejection.

Gestures reflect subconscious thoughts and feelings seeking expression. Gestures also influence thoughts and feelings in the observer. Body language is usually an unconscious reflex that expresses a feeling that has not been allowed vocal expression. However, some “actors” (eg, malingerers) may consciously apply body language in a few learned pantomimes to portray a feeling associated with a role.

Just as a doctor does not make a diagnosis based on just one symptom, so the interpreter of body language should be cautious in arriving at a judgment based on one or two attitude signs. Where one or two signs may be ploys to distract the observer, several signs expressed consistently serve as indicators to the experienced observer. The important thing is to weigh all evidence before arriving at a firm conclusion.

Other Forms of Nonverbal Communication

Self-fulfilling prophecies are communicated as much through nonverbal means as they are through direct words. Psychologists have long known that something as simple as a friendly smile offered when test sheets are passed out can raise the subjects’ score. Students respond to their teacher’s wordless expectations communicated through subtle facial gestures and voice tones as employees do to the nonverbal communications from their supervisors. Nonverbal communications serve as a medium in which one person’s feelings and ideas are transmitted to another quite readily. The influence of such interpersonal expectation appears to vary with individuals in its clarity and effectiveness, however. These signals are mixed and contain subtle sequences and rhythms between voice tones, facial expressions, and bodily gestures.

An individual signal need not exceed a fraction of a second in duration to be interpreted. This draws attention to why action often speaks louder than words and why it is difficult to deceive the trained observer solely with verbal persuasion.

Eye Blink Rate

Hidden cameras used to record the eye-blink rate have shown that how fast a person blinks his eyelids is a good index of his state of inner tension. The normal rate of about 32 times per minute decreases during deep relaxation and hypnotic-like states, and increases rapidly during anxiety. Tests also have shown that when a person is not telling the truth, the rate of blinking rapidly increases from normal even if the person consciously tries to inhibit the reaction.

Pupil Reactions

Research has shown that the pupils of your eyes will reveal that you may be lying as well as indicate some of your innermost feelings. Some researchers believe that pupil size is a more accurate lie detector than the polygraph. Studies show that pupils distinctively dilate (become larger) when a person likes what he sees or is interested in it. Conversely, pupils contract (become smaller) when the subject is presented with an object or situation he dislikes or finds dull.

Handling the Emotionally Disturbed Patient

Positive human relations, dispensed by both doctor and assistant, is in itself a therapeutic agent of utmost value. Its effect has proved beneficial in almost all ailments that beset mankind. It may be curative solely by its own presence, or it may require assistance from other persons or therapies. It should frequently be combined with other forms of treatment.

Psychotherapy can be loosely defined as anything one person can do to improve the mental or emotional state of another person. Thus, it is anything that helps an individual cope with his feelings, motivations, behavior, or performance more effectively.

Words are not the only tools available. Doctors and assistants can influence others by their acts, manner, and attitudes possibly more than they can by words. It would be rare to talk a person out of an advanced mental disorder, soothe him with platitudes, pacify his concerns, or resolve his problems strictly by your prescriptions. Psychotherapy essentially is listening, giving and receiving feedback uncritically, helping a person develop his own solutions, helping the person develop confidence, and letting him talk things out and release bottled-up feelings.

The doctor’s use of basic principles of psychotherapy involves a thorough history that is constantly updated, arriving at a differential diagnosis, creating formulations, and selecting a clinical approach specially designed for the individual patient. A positive doctor-patient relationship is probably the most important therapeutic measure available to any patient.

Listening attentively, being yourself, and showing personalized interest in the patient are powerful therapeutic measures available to the chiropractic assistant. The essential key to good care for the patient is in caring for the patient. This should be the entire staff’s basic motivation.

The Underestimated Value of Applied Psychology

As a therapy in itself, positive human relations serves to function as a cure sometimes, a relief often, and a comfort always. In its superior form, it helps to prevent sickness. In its mediocre form, it attends to impending sickness. In its inferior form, it “treats” the symptoms of sickness.

The therapeutic effects of positive human relations are witnessed through a variety of methods; eg, listening, analyzing, and counseling. Besides its therapeutic value, it also has a diagnostic potential. It functions in diagnosis by alert observation, listening, responding, contacting, touching, testing, and interpreting. It serves as a contrast medium to emphasize the normal from the abnormal and subnormal, the real versus the unreal.

This “miracle” therapy of positive human relations is indicated in almost every conceivable physical and emotional ailment that besets mankind. It should be applied freely in all structural, functional, and traumatic disorders, and is particularly helpful in psychologic problems. It has proved its value in neurosis, career problems, marriage problems, and sexual problems —whether occurring singularly or coexisting with a disease process. It should be used liberally since it has little benefit when diluted.

Dependency

Therapeutic psychodynamics should not be used as a substitute for handling a problem that the patient is capable at the time to handle himself. Thus, it should not be used as a crutch. As any therapy, positive human relations can have an adverse reaction. Because of its potency and capability for relieving stress, a patient may become dependent on it and even addicted to it. Too frequent requests for office visits and telephone counsel are symptomatic of dependency. Severe anxiety and depression may result during withdrawal of the therapy. Disappointment may result in despair, anger, or resentment.

While an overdose of this powerful therapy may occur, underutilization is much more common.

The Application of Psychiatric Principles

One survey revealed that approximately 12% of problems presented by patients in a typical outpatient practice were clearly psychiatric in nature and that psychiatric problems were the second most frequently presented complaints. From 20%—80% of general practice will require some use of psychiatric principles. Every successful practitioner, regardless of discipline, is aware of this necessity.

Here are some assumptions regarding the management of psychiatric problems:

1. Psychiatric treatment and the use of psychologic principles in everyday practice represent a necessary and desirable dimension of competency for both doctor and assistants.

2. The primary-care physician should obtain and maintain astute awareness of the psychologic factors present in all illnesses whether these illnesses present as physical or psychiatric problems.

3. The primary physician should obtain and maintain a considerable degree of skill not only in recognizing psychiatric problems but also in managing these problems on a continuing basis.

4. Primary physicians should have a familiarity with the body of knowledge available regarding human growth, development, and behavior throughout the life cycle and at each stage of the cycle. This is regarded as core-content knowledge.

5. Core-content knowledge is not enough. Physicians (and assistants to a limited degree) should also develop core-content skill in putting this knowledge to use in the practice just as any doctor must develop and refine his clinical skills. These skills, once developed, can be lost due to “disuse atrophy” or lack of feedback. Education in this field must be continual to keep alert to the current state-of-the-art.

6. Some of these core-content skills involve the following:

— Handling doctor-patient and assistant-patient relationships
— Good counseling and interviewing techniques
— Awareness of the role of the illness in the patient’s psychic and social economy by the doctor
— Self-awareness
— The appropriate administration of somatopsychiatric therapies.
— Attributes of consideration, compassion, acceptance, empathy, responsibility, and flexibility
— Problem helpfulness and resolution ability
— Use of family members in the treatment process.

Psychiatric illnesses have two common characteristics. They take time, and they deserve more than commonsense advice. As some patients require specialized services, the doctor should have knowledge of community resources for handling emotional and psychiatric problems. The doctor also should have a friendly professional relationship with local counselors, a psychologist, and a psychiatrist with whom he can discuss and refer patients when necessary.

7. Every family physician is exposed to the entire range of psychiatric problems (from mild to severe). Thus, he must be able to recognize and manage them on either a continuing or emergency basis according to his skill, desire, and the patient’s needs and consent.

All patients presenting with psychiatric problems do not require the specialized care of a psychologist or psychiatrist, and only the most severe cases require hospitalization. The clinical judgment of when or how to refer a patient to a specialist is one of the core-content skills of the doctor. Often, the primary physician can treat the illness effectively.

The assistant must be aware that patients with major or minor mental or emotional illnesses are human beings who are suffering. They are seeking help to cope with the problems of life. Like a patient with a purely structural disorder, they have a right to be treated with dignity and concern. They are not malingering. A patient suffering a psychiatric illness has a right to be in the doctor’s office and receive the best chiropractic care possible. Such patients are never “taking the doctor’s time” without cause.

The experienced doctor will be alert to treat the patient as well as the complaint. The nature of recommended therapy should be based on the individual needs of the patient involved. Some patients require only simple advice while others need in-depth counseling or possible referral. All patients require understanding.

The Assistant’s Role in Case Management

While the doctor understands that patients with psychiatric illnesses require special considerations, he may fail to offer all assistants specific instructions regarding what to do or not do. Here are some basic recommendations that he will likely expect an assistant to understand:

— Be empathetic, not sympathetic. With empathy you place yourself in the other person’s position so you can appreciate his experience. With sympathy, you feel with the patient and most likely will take on the patient’s feelings of hopelessness and fear.

— Do not give pep talks, preach, threaten, bribe, or moralize. Don’t do anything that implies that the patient could change if he would change. Will power by itself is rarely the answer. Since there is a difference between sin and sickness, and a patient’s behavior and values may be different from yours, do not attempt to set or enforce your morals. Never advise a patient to “have faith,” “keep your chin up,” or “try a little harder.” Patients will feel rejected by such vague generalities and trite comments. Likewise, do not advise patients to “straighten up” or “pull yourself together.” If they could, they would. Most likely they have tried and failed repeatedly. They need professional help.

— Be reality oriented. Separate fact from opinion. Be professional, poised, and do not let yourself be emotionally drawn into the patient’s problems. Be helpful whenever possible, but recognize that the patient’s troubles are those of the patient and not yours. Treat the patient as an adult who you may be able to help, not some child you should lecture.

— Do not hold the belief that a patient’s problems will automatically disappear with a new job, a new hobby, a new spouse, a vacation, or some other change in environment. Changes in scenery only result in old problems in new places. The problem must be assumed to be with and within the patient; ie, the problem moves with the patient until it is resolved.

AN OVERVIEW OF PSYCHIATRIC DISORDERS

Some psychiatric problems can be roughly compared to the severity of a common cold. Some are like mild pneumonia, others like moderate emphysema, but only a few are considered malignant. Psychiatric illnesses, as most health disorders, rarely have a sudden onset. They develop slowly, and symptoms only may appear in the later stages. The dynamic symptoms are but the tip of the iceberg.

It must be recognized that as pain and fever fulfill a specific and helpful purpose in the survival process, so do psychiatric symptoms. The doctor must be concerned with what caused the symptoms plus what is maintaining them now.

It also must be assumed that the patient has had his successes and failures, has learned to relate to other people, and has learned to work and live and survive in a relatively suitable manner. A new problem arose, the patient tried to cope with it according to his experience, and efforts have failed. Why have previously successful methods of solving problems failed this time? Is the reason the patient or the situation? Can the problem be resolved or must the patient learn to adapt?

Coping Mechanisms

All behavior is purposeful, even neurotic behavior. Behavior is never random or capricious. It is goal oriented. People attempt to adapt to their environment as they perceive it. Behind every action lies a reason related to the life history of the individual and associated with an emotional or physical need. Ahead of every action is a goal, a purpose, a promise of need gratification. Thus, all behavior is some type of coping mechanism, and all that psychotherapy can do is attempt to improve an individual’s coping skills. In psychiatric illness, every symptom can be considered an action—an action that has a need behind and a purpose ahead.

As a coping organism, an individual lives a life beset by three basic types of problems and influences: (1) problems rising from the external environment, (2) stressful inner feelings resulting from memories of past actions or refusal to act when capable (guilt), and (3) impulses within arising from sanctions and prohibitions of a moral or ethical conditioning acquired since childhood (conscience).

A coping individual must defend against these attacking forces by warding off attack by some shielding mechanism (eg, flight, rationalization) or by acquiring a weapon to attack or alter internal and external negative environments (eg, fight). In other words, he can (1) attack, change the environment or act to alter it; (2) retreat, run away to avoid the stress of the environment, get out of the situation, surrender; or (3) coexist, adjust to the problems in the environment, change the environment or the self a little, tolerate an undesirable situation if a better one cannot be developed. These are rational alternatives, but they are rarely accepted as by involved patients. The typical patient suffering a psychiatric illness seeks a magic wand, frequently going from doctor to doctor in quest of an easy solution to a difficult problem.

While physical impairment can be readily measured, psychologic impairment is difficult. How sick is sick? If a patient is in pain, we know he is sick, but we do not know how severe or widespread the sickness is. The same is true of psychiatric distress. The degree of psychiatric illness can be determined only by the methods the patient uses to cope with the stress. Whenever a person is confronted with a problem, he calls on his coping mechanisms to help re-establish the status quo before the stress occurred.

If the stress is more severe than the patient can handle, the individual is forced to resort to more pathologic coping mechanisms that are classified into five levels:

1. Alarm and mobilization, characterized by anxiety, inefficient hyper-activity, frustration, withdrawal and depression, and sympathetic nervous system responses in preparation for fight or flight.

2. Partial detachment and attempted compensation, characterized by neurotic symptom formation and behavior, less obvious anxiety, erratic and nonproductive behavior, and the development of phobias, obsessions, compulsions, intoxications, addictions, or somatizations.

3. Transitory ego rupture with prompt restoration, characterized by severe neurotic and brief psychotic episodes such as panic attacks, catastrophic and demoralizing feelings, irrational excitement, violent behavior (homicidal, suicidal, sexual, or convulsive) of a temporary episodic nature.

4. Persistent ego rupture or exhaustion with marked detachment, characterized by varying degrees of erratic excitement, disorganized behavior, withdrawal, apathy to the point of inactivity and unresponsiveness or even mutism, hallucinations, delusions of persecution or grandiosity, confusion, bewilderment, forgetfulness, and disorientation. Most patients at this stage require institutional care.

5. Complete ego failure, characterized by continuous uncontrolled violence or retarded depression ending ultimately in death unless controlled. Most primary physicians will treat patients using first- and some second-order coping devices. Specialists are necessary for the treatment of severe levels in a restricted environment.

As explained, if a doctor is to treat a psychiatric illness adequately, he must determine how did the patient got sick and what keeps the sickness going. Remember that psychiatric illness does not “just happen” any more than pneumonia or a slipped disc just happens: illness (physical, functional, or psychiatric) develops for one or more reasons. The development of a neurosis HAS seven aspects: (1) a predisposing personality, (2) a current conflict, (3) an external precipitating stress, (4) the development of anxiety, (5) a primary gain (symptom-forming factor), (6) the symptom complex, and (7) the secondary gain (symptom-fixing factor).

The Person Behind the Illness

A person with a pure personality problem will rarely appear in the doctor’s office consciously seeking help for the problem. Almost always, he comes because of some physical or functional symptom or disability. Thus, it is important to keep in mind that behind the problem presented is the patient’s basic personality. He has always had this personality and will always have this personality (modified only according to profound conditioning). He is a unique individual. There is no one else like him. He has his own way of handling stress, and he will try in the future to handle new stresses in like manner. In this sense, behavior becomes quite predictable.

Psychoanalytic theory holds that an adult neurosis develops from the roots of a childhood neurosis. While we can assume that some degree of childhood neurosis existed, that memory is often forgotten. Still, adult symptoms often mimic those occurring in childhood. As the personality develops from childhood to adulthood, habitual behavior becomes more rigid and presents with a somewhat fixed behavioral pattern. Thus, in adult neurosis, we often see an adult reacting to stress as if he were immature.

A psychiatric illness is usually associated with a current conflict or problem that is perceived by the patient as a threat. Conflicts such as marriage problems and career dissatisfaction involve the person’s self-image that are superimposed on and related to the predisposing personality. During the course of treatment, the patient may reveal this current conflict to the doctor, he may conceal it, it may be repressed from conscious awareness, or the patient may fail to see its relationship with his symptoms.

It is understandable that a patient with a predisposing personality and a current conflict is waiting for something to happen. Based on experiences, he seeks solutions to his problems. Neurosis resulting from chronic stress in ineffective problem solving is usually precipitated by some external situation. This explains why the illness manifested when it did, but this external precipitating stress should not be confused with the current conflict. If a person is having a current conflict in his marriage and attempts suicide, some specific external stress must occur to precipitate the act when it did. For example, chronic feelings of insecurity (current conflict) might have been augmented by learning of his spouse’s infidelity (external precipitating stress).

Tolerable or intolerable anxiety occurs in stress when the individual doubts his capabilities of successfully applying fight or flight mechanisms. On recognizing an impending danger and possessing feelings of inadequateness, the inability to solve problems results in anxiety. Thus, we have the quality and quantity of anxiety and its manifestations superimposed on (1) the predisposing personality, (2) the current conflict, and (3) an external precipitating stress. Now, if the stress becomes long standing or very severe and the anxiety becomes overwhelming, secondary defense processes are forced to manifest.

Psychiatric Symptom Formation

When an individual can control anxiety by applying healthy defense mechanisms, illness does not result. However, when unhealthy defense mechanisms are applied, illness invariably results. The strength of the personality determines its ability to tolerate stress. Whether by healthy or unhealthy means, the primary gain in the illness process is the relief of anxiety. These means or mechanisms themselves are often witnessed as symptoms such as forgetting recent events or conversations. Such symptoms are therefore the result of the patient’s attempt to control anxiety. The symptoms manifest in a wide variety such as development of an aversion, a phobia, a compulsion, an obsession, a temperament change, a psychosomatic syndrome, or some schizophrenic world of fantasy.

Unfortunately, these symptoms are accompanied by increased anxiety and/or depression that tells us the symptom was not totally successful in relieving the anxiety. Thus, a cause must be found behind the symptom. The paradox is that the symptom, as the most dynamic factor, tends to conceal and reveal. The symptom also creates the secondary gain or symptom-fixing factor.

Even if the cause behind the symptom is known, what keeps it going? The concept of secondary gain is the most recognized answer to this question. The symptom is not easily given up by the individual because he has learned that it offers certain advantages in relieving some anxiety. To give up the symptom means to confront the basic anxiety again, and the patient wishes to avoid this at all costs if possible.

Besides the emotional rewards, there also may be another reward in not giving up the symptom. For instance, the man having marital difficulties who develops a heart condition from “overwork” may unconsciously recognize that his continuing disability will help prevent his wife from leaving him. In fact, he may unconsciously do things that will discourage healing. Likewise, a woman with a “back problem” may recognize that her continuing disability will help her receive more attention and help from her husband. Thus, she may unconsciously do things to delay recovery (eg, heavy lifting, falling). If this is done consciously, the patient is malingering. But secondary gain efforts, being unconscious, are definitely not cases of malingering.

To complicate the matter, the patient may consciously or unconsciously become aware later in the process that there is a financial reward for the presence of an illness, disorder, or symptom in the development of secondary gain. This is commonly seen when the possibilities of financial settlement for an industrial or automobile accident become apparent. This might be observed in the patient progressing on schedule who suddenly has a “relapse.”

The aim of a psychiatric symptom is to distract attention from the real problem. Unfortunately, while it tends to relieve anxiety in one area, it tends to cause anxiety in another. A symptom should be viewed as the outward sign of an inward problem. That is, while the individual tries to hide unacceptable feelings and create a symptom designed to control the anxiety, attempts become outwardly apparent to the keen observer. Thus, the attempt to conceal can actually reveal.

The psychiatric symptom (psychologic defense mechanism) manifests as pathologic behavior expressed in thought and action. It is characterized by irrational behavior beyond conscious control; thus, it is involuntary. If it were under conscious control, the symptom would be viewed as normal problem solving, adaptive, purposeful behavior. Besides being involuntary, the psychiatric symptom is never really successful even if it is purposeful but it does help to relieve part of the basic anxiety. Because of this, the individual is afraid to give it up.

During therapy, the doctor must determine why the symptom manifested when it did, under what circumstances it occurs, and why it occurs under some situations and not others. Why does it occur at night but not in the morning? Why does it occur at home but not at work? What purpose does the symptom fulfill for this individual at a particular time?

As the doctor studies the psychiatric symptom, he must consider its four aspects: (1) as a coping device; (2) as an attempt at adapting, with the risk that maladaptation may lead to personality scarring; (3) as a purposeful defense mechanism designed to shield against or avoid anxiety; and (4) as a tactic to survive within interpersonal relationships.

The personality changes with development of the symptom as the old personality and new symptom unite. As the symptom is now part of the individual’s coping technique, it can be used for secondary gain to obtain something previously perceived denied or defend a possession previously felt to be in jeopardy. Thus, the illness may unconsciously be used to maintain a disintegrating marriage, gain financial compensation, avoid unpleasant career situations, manipulate people, express hostility, or satisfy thwarted needs or have them fulfilled by someone else. Thus, the individual unconsciously tends to view the symptom as a definite asset—but not completely because there is a conflict.

The symptom that is an expression of a wish, usually a forbidden wish, expresses itself along with denial of the wish. It is as if one part of the personality is saying “go” while another part is saying “stop.” Dreams also can express a forbidden wish and a denial of that wish, and this is the basis of dream analysis according to Freud.

When a doctor analyzes the psychiatric symptom, he can perceive the adaptive and defensive mechanisms used by the patient. Armed with this knowledge, the doctor can then analyze other symptoms and coping methods used to face life. Again, coping patterns tend to result in repetitive behavior that is fairly well predictable.

Authorities define symptom characteristics slightly different. Neurotic behavior was viewed by Eric Berne as game type behavior in transactional analysis. He taught that there is always an ulterior motive with a pay-off, the act is unconscious, and it involves another person. Jay Haley stated that it is the result of some extreme influence, the behavior is beyond conscious control, and it involves another person. Freud’s position was that the behavior was unconscious, was an expression of both a wish and a denial of a wish, was designed to solve a problem but is unsuccessful, is related to childhood neurosis, and usually involves another person or persons. These authorities view neurotic behavior as coping behavior, unconscious and involuntary, repetitive, reflecting a conflict within oneself or about someone else, and indicates the general coping behavior of the person.

Understanding Anxiety and Depression

Anxiety

Anxiety is an unpleasant feeling or apprehension of danger often characterized physically by rapid heart beat, shortness of breath, palpitation, pupil dilation, extremity paresthesia, nausea, and/or anorexia. It may be strictly of mental origin or be a symptom of physical illness as in acute heart attack, alkalosis, hyperventilation, or a reaction to or a complication of a wide range of physical dysfunctions. It can defend against, substitute for, or precipitate depression. In schizophrenia, it may be a symptom of dammed-up psychologic tension. Regardless, it is viewed as the essential element in the development of mental illness whenever noted.

Anxiety occurs when an individual feels that something will happen and the subject lacks control. As all behavior is purposeful, anxiety has an aim—an attempt at protection from internal and external dangers. It alerts the personality to a threat, it prepares the body physically for a “flight or fight” response, and it alerts the individual’s defenses. In many instances, an anxiety response is healthy. It is maladaptive when the anxiety is so severe that the threat is not realistic to the response.

Differentiation

Anxiety is referenced to the future; depression is oriented to the past. With anxiety, a person is afraid of what might happen. In depression, a person feels hopelessness because of something that did happen. Anxiety is linked with fear; depression, with guilt. An individual expresses anxiety when he perceives a threat and feels helpless. A person expresses depression when he perceives a loss and feels hopeless. Thus, an individual may express both anxiety and depression if he perceives a threat and has feelings of hopelessness. Frustration is the result when a person perceives a wish or a need and simultaneously feels helpless in acquiring the wish or need.

Depression

When we hear the word depression, we usually think of an individual being blue, sad, sorrowful, melancholy, or in very low spirits. However, depression as a clinical syndrome is more broadly defined. Psychologically, depression is a response to a loss, especially a loss of self-esteem. As anxiety, it can be a symptom of physical disease as well as be of mental origin. It is frequently associated with cancer and viral infections because of the illnesses and their restrictions. It also may be the result of a loss of income, a loss of somebody close such as in death or divorce, or used as a defense against or a surrender to anxiety. Depression can be viewed as anger turned inward —repressed hostility showing distinct biochemical changes within the body.

The five cardinal symptoms of depression are (1) the patient looks tired (fatigue) and acts tired (psychomotor retardation); (2) self-neglect in attire, personal sanitation, grooming, etc; (3) feelings of dejection, sadness, guilt and sorrow, (4) loss of social interest with a tendency toward withdrawal from people, things, food, sex; and (5) characteristic insomnia: the individual falls to sleep rapidly but awakens in the middle of the night and has difficulty returning to sleep.

Depression is greatest in the morning, but eases as the day progresses. Other characteristics include dependency, guilt, dire hopelessness, loss of self-esteem, distorted thought processes, indecisiveness, narcissism, mixed feelings of love and hate (ambivalence), and the physical symptoms of fatigue.

Organ Language and Psychosemantics

The study of psychosomatic illness reminds us that the control of body functions makes a lasting imprint on the mind and becomes part of mental processes. As we learn to control our bodies and their biologic functions, we build our psychic structure. The mind is not created independently of the body. It is very definitely linked with it.

Many authorities suggest that the most satisfactory way to deal with tension is by action, the least satisfactory is by thought, and in between is speech.

Neurotic Symbolism

A person suffering from psychosomatic illness can be compared to a heated tea kettle. If steam cannot escape from the spout, the lid blows off. In a similar way, people accumulate tension that is almost certain to explode in symptom formation. The point is that tension (energy) should be used in productive work or speech. Short-circuited energy can disturb body function. If a person cannot express tension by acts, thoughts, or words, if they cannot express what is disturbing them, then one or more of their organs will try to say it for them. Thus, the person with nausea, who lacks evidence of organic disease, may be indicating that he cannot “stomach” situations. The person with an itch often “lets things get under his skin.” Careful observation finds that body language expresses in many symbolic formulas.

The function of the mind is to promote the control of ourselves and our relations to other people. Remember that when feelings and thoughts exist that cannot be expressed by words, thoughts, or actions, they may find expression through some organ or system. The result is a “language of the organs” that can express itself in illness if the personality is not sufficiently developed to solve its problems through other channels. The organ that “speaks” is most likely the organ whose function was in ascendancy when environmental conditions were threatening and produced pain (anxiety). But constitutional predisposition, identification with an authority (eg, boss, parent, teacher), or other factors may also determine the “choice of organ.”

In the context just described, it can be recognized that physical symptoms are often symbolic of neurosis. A feeling of oppression in the chest accompanied by sighing respiration in the absence of organic findings mat suggest that the person has a “load on his chest” which he would like to get rid of by talking about his problems. The person who has lost his appetite and consequently become severely undernourished is often emotionally starved as well as physically starved. The common symptom of fatigue may be due to an emotional conflict using so much energy that little is left for other purposes.

Emotional tension of unconscious origin frequently expresses itself as muscle tension leading to aches and pains, and sometimes these are represented by sharp pains such as seen in neuralgia. An ache in the arm may suggest that the person would like to strike someone but is prevented from doing so by the affliction. Itching can represent dissatisfaction with the environment in which the individual takes out on himself; martyr-like, he scratches himself (shows aggression) instead of someone else. “Weak legs” and vertigo are common physical expressions of anxiety. The digestive tract is, above all other systems, the pathway through which emotions are often expressed.

Alert Listening

Casual remarks can offer important diagnostic clues. Be aware of the importance of side remarks and apparent irrelevancies because important clues are often obtained in this way. Considerable anxiety may also be hidden behind laughter and jokes. The middle-aged man who with a laugh “guesses that he’s cracking up” is often referring to his anxiety regarding his potency and future usefulness. The middle-aged woman with her half-expressed anxiety regarding the imminence of menopause may be anticipating the end of her femininity. Both expectations are, of course, based on false beliefs that may require discrete clarification by the doctor.

An interesting analysis of the semantics of organ language shows that expressions concerning organ function exist as close parallels in many languages. The study found several ways in which words for organs and their functions are employed to indicate some degree of psychosomatic influence.

1. Some expressions imply a conscious awareness of the autonomic concomitants of emotional reactions. For example, “to be scared spitless” or “it makes my flesh creep.”

2. There are expressions in which the word for an organ is employed as a substitute for an emotional attitude. For example, “soft-hearted” or “have guts.” Some of these expressions have a shade of concrete physiologic meaning. For example, “spineless” or “no backbone,” referring to the loss of muscle tone associated with a lack of initiative.

3. One group of expressions has implications proved accurate on psychoanalytic methods. For example, “I can’t stomach him” or “I’ll just have to swallow the consequences of that decision.”

4. Another group of expressions indicates a long-standing awareness of psychosomatic relationships. For example, “Just the thought of that gives me a headache.”

GENERAL EDUCATIONAL OBLIGATIONS

Although the typical patient may be in the office for a considerable time, the doctor will not have the opportunity to spend a great deal of time with each patient. The majority of total office time will likely be spent in contact with one or more assistants. Thus, while the doctor has a relatively brief time to develop the doctor-patient relationship, assistants have a greater opportunity to enhance this relationship.

Developing Levels of Consciousness

Each doctor and assistant has the professional obligation to develop three distinct stages of consciousness within each patient. These are (1) health consciousness, (2) chiropractic consciousness, and (3) Dr. X consciousness. From the viewpoint of an individual practice, consciousness of the individual doctor is most important concerning practice stability. If the patient is just health conscious, he may hold the opinion that he can treat himself adequately and thus be vulnerable to the dangers of over-the-counter patent medicines and home remedies. While chiropractic consciousness is a higher level than health consciousness, it does not insure the security of the practice. However, if the patient is Dr. X conscious, he is at the same time both chiropractic conscious and health conscious.

Office Literature

Because of time limitations, the doctor’s influence cannot rest on the office visit alone. Patient instruction sheets help to extend the doctor’s influence. The use of printed guides and instructions also offer constant reminders of the doctor’s services. Their use helps to minimize errors in communication, they save time in repeating oral instructions by the doctor and assistant, they impress patients with the office’s thoroughness and efficiency and make the patient more receptive to recommendations, and they indicate special consideration for the patient’s welfare by not depending on the patient’s memory.

The alert doctor and assistant will be aware that the typical patient is not interested in the technical aspects of their condition. They are interested in the removal of pain, discomfort, and how the condition affects their lifestyle. 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.

The practice has a moral obligation and responsibility for the patient’s health. Thus, the doctor should anticipate possible patient stress by questioning the patient about common activities. If the patient is left with the impression that the doctor is only interested in him when he is in the office, the patient will question the doctor’s motives. Confidence in the doctor will diminish. The doctor can enhance confidence by showing the patient how to avoid overstress during the holidays, while on vacation, and during spring cleaning, sports, or recreational activities. Helpful tips on eating and sleeping habits are often appreciated. Special instructions during the prenatal and postnatal period are welcomed. This will show that the doctor and assistant care about the patient’s welfare.

Many commonly used patient instruction sheets, diet forms, exercise routines, and safety measures while lifting or on vacation are available from the American Chiropractic Association.

HUMAN RELATIONS IN PATIENT CONTROL

Patients initially believe that they will receive competent service when they enter a doctor’s office. They receive service, pay for it, and leave with the conclusion that they received what was expected. Patients are under no obligation to refer others to the practice. They paid for what they received. Yet without constant patient referrals, a practice cannot grow. New patients must be available to replace those who are dismissed, die, or move from the community.

Building Good Will

The question arises: What motivates patients to refer others? The answer is found in the answer to another question: Why does one technically competent doctor have a highly successful practice while another technically competent doctor has difficulty in maintaining his practice? The answer is that the successful practitioner and his staff place emphasis on building positive human relations.

Almost invariably, the successful practice will be characterized by patients receiving the VIP treatment. Alert staff members are hosts and hostesses to every patient in the office. They recognize that the average person is hungry for attention, and attention is freely served. Patients are thanked. Patients are appreciated. Patients are complimented. The watchword is hospitality. Patients are allowed to talk, to express themselves, and to question. Good assistants are good listeners.

The successful practice has a staff that likes to brighten the day for patients with a kind word, a friendly gesture, a compliment. A patient’s positive acts are praised. Promptness in appointments is praised. Prompt payment of bills is praised. Prompt recovery is praised. Cooperation is praised. Such praise is not idle flattery; it is sincere recognition.

The staff of a successful practice is considerate, thoughtful, and sympathetic. Patients’ birthdays and anniversaries are remembered. The staff is aware when a patient’s daughter graduates from college or a son enters a new business. Alert offices make a point of knowing such things and sending a thoughtful card or offering a considerate comment. The considerate staff knows that while few patients may avail themselves of office coffee, tea, or fruit juice, all patients appreciate the gesture. A few raincoats or umbrellas available for loan to help the patient caught in an unexpected shower are a sign of special consideration. Yes, patients will talk more about such extra kindnesses than they will about excellent technical service that is expected. It is doing more than the expected that counts.

The staff of a successful practice never argues with patients. The staff agrees, and refers to the constraints of “office policy.” Yet, flexibility is always offered when possible. Patients are allowed to express their point of view, and their suggestions are always given sincere consideration. If you win an argument with a patient, you lose the patient. Without patients, there is no practice. Without positive human relations, there is no practice growth. Any assistant or doctor who becomes irritated by eccentric patients or becomes arrogant or too impressed by his or her dignity is their worse enemy to success.

As explained previously, patients who are sick or disabled are worried and fearful. The staff of a successful practice recognizes this and offers assurance within ethical bounds. Constant reassurance, encouragement, and inspiration help the patient continue with the recommended treatment plan. Doubt, discouragement, and apathy result in patient “drop-outs.” Continual explanation results in reassurance. Even slight results offer encouragement, for results are facts. When results become more evident, the patient is inspired. During inspiration, when the mind is in a high state of expectation and belief, it is highly receptive to suggestion.

Successful human relations is giving patients what they do not expect or more than they expect. It’s a warm smile, attention to a new hair style, the availability of a lending library, a “smile” button on dismissal, a sense of humor, a concern for the personal touch, an “I care” attitude, a small bowl of mints in the reception room, or a list of “health and safety tips” for patients planning a trip. Is it so unusual that patients will be motivated to do “something extra” for the office that does something extra for them?

Every human being has certain preferences, beliefs, theories, convictions, and habits—some good, some bad. Doctors and their assistants are no exception. However, it is very detrimental to positive human relations when a doctor or assistant attempts to persuade patients to accept their ideas as gospel. A patient’s smoking habits, eating habits, or sexual habits are none of the staff’s business unless there is a direct proved connection to the habit and the patient’s condition. If smoking bothers you or other patients, it is good policy to improve the ventilation or provide a special area. If you prefer a vegetarian diet, keep the fact to yourself. If you are a “born again” Christian, that’s your personal business. If you like to have a cocktail before dinner or are a total abstainer, the average patient could not care less and resents your attempting to impose your ideas.

Patients are human, and humans are not perfect. They prefer not to be. They enjoy many habits of which you might not approve that they feel are none of your business (and they are probably right). They come to the office for a health service, not a lecture or a sermon. When you accept patients as they are (a combination of strengths and weaknesses), they will accept you. You have your hang-ups, patients have theirs. Accept this, and go on to provide what patients want in a manner better than their expectations.

Preventing Patient Drop-Outs

While clinical chiropractic is science oriented, the practice of chiropractic must be patient oriented if it is to achieve its potential for success. Patients are human. They are people struggling with their health problems, family problems, financial problems, career problems, and a multitude of other concerns.

Remember that the successful practice is a humanized practice, one that recognizes patients as they are, not as you might wish them to be. The staff that builds a successful practice is not one that lives in a pseudotechnical-scientific ivory tower—ordering patients about, talking to them in professional jargon, subjugating them with airs of superiority, or inferring patients’ ignorance in health habits. The successful staff is one that offers the public an opportunity to share its knowledge, experience, services, and facilities upon request.

Meeting Patient Needs

The successful office recognizes that patients present both physical and emotional needs and tries to the best of its ability to fulfill these needs within a professional atmosphere. This takes identification with and a willingness to relate to human beings, especially sick human beings. In the same manner, patients must relate to the doctor and his assistants. This takes encouragement and rapport conditioned by agreement, faith, and inspiration.

We are living in what some have called the “Computer Age” or the “Space Age.” It is true that science and technology are evolving faster in a few months than they did in several decades a generation ago. We live in an era of rapid change: changing environment, changing values, changing morals, and so forth. With such change, we witness more emphasis being placed on “image” than “substance,” more interest in masks than the faces behind the masks.

The “professional image” of the health practitioner so often portrayed today is one of an efficiently programmed, never wrong, scientific superbeing. It should be remembered that the friendly, homespun, often bumbling but always human doctor of years past had little worry of a malpractice suit.

The word personality comes from the Greek word meaning mask. Patients wear masks, doctors wear masks, and their assistants wear masks. We all try to hide our real selves from the world. In humanizing the office environment, we must learn to drop our masks: to be caring, open, honest, and kind. We are not dealing with “patient Smith,” “the 3:15 appointment,” or “the patient with tennis elbow.” We are dealing with friend Mary Smith, Pastor Brown, or Jimmy Burns.

We should learn to look through the masks of patients to see the real person. This is how we harmonize with feelings, and feelings are always the precursors of actions. Such rapport is not always easy to develop, but it’s the magic of human relations. Armies follow generals who have this magic, often to the ends of the earth and their own destruction. Employees burn the midnight oil, great attorneys mystify juries, zealots are created in causes, and patients become referral centers when caught up in the “magic.”

It is strange that some staffs forget that people do not like being sick. They are not in a doctor’s office by choice. They are bitter and resentful of being forced into a painful situation against their will. The chiropractic assistant should not become intimidated by this situation. Do not, in fear of saying the wrong thing, draw yourself inward as a turtle and say nothing under the excuse of being shy. Shed your shell by not seeing a “patient” before you but a potential friend. Be understanding, be concerned; show empathy and kindness, but be natural. Let your warmth express naturally to turn a stranger into a friend, a welcomed guest.

Avoid Self-Prophesies

Be careful of your expectations. People have a way of fulfilling your prophecies. Assistants who expect patients to be cordial, cooperative, prompt, and friendly will find that patients reflect this attitude. In contrast, the assistant who expects patients to be irritable, uncooperative, or even hostile will find her predictions come true. When effects are not to your liking, change the cause. You will find by experience that you have the power to determine the attitudes and actions of others by your attitudes and actions.

Advantages of the Humanized Practice

While every practice has its share of drop-outs, the successful office keeps the number to a minimum. Although every patient may not need intensive health care, everybody needs some form of health maintenance or preventive program. Patients do not become drop-outs because their needs were fulfilled; they drop out because their needs were not being fulfilled. They were forced to seek fulfillment elsewhere. When a patient abruptly switches from one practitioner to another, it is because the motive to “switch” became greater than the motivation to stay.

When a practice is humanized, a few happy patients lead to more happy patients. The reverse is also true: when a practice becomes dehumanized, a few drop-outs lead to many more. Both positive human relations and negative human relations are contagious. Some practices may exist by advertising volume alone with a large turnover, but they will never be successful in the true sense of the term—nor will such offices be happy places in which to work.

A bruised ego often prevents one from realizing the cause of drop-outs. Symptoms preceded the act, but they were not recognized: dissatisfaction, unappreciativeness, uncooperativeness; chronic late, missed, or changed appointments; collection problems; no referrals. When these symptoms are noticed, they indicate a breakdown in human relations, a breakdown in communications, a breakdown in motivation.

What the Doctor Expects

While your doctor-employer will expect you to sincerely try to please everyone, he knows that it is impossible to please everyone every time. Some people are difficult to reach. The realist is aware that 5% of the patients will cause 95% of your problems. But you cannot spend 95% of your time coping with 5% of the patients. You must serve all. Each practice has its personalities, procedures, services, and facilities that will appeal to many but not everybody. If you or the doctor spend too much effort in trying to satisfy the eccentricities of a small minority, you may dissatisfy the majority. This would be self-defeating.

We are living in a very mobile society. The typical family moves on the average of every 5 years: six or seven times in a lifetime. Moving or being transferred from the community is a cause of unavoidable drop-outs, but new referrals must replace these patients. For this and other reasons, most doctors will maintain statistics to arrive at a drop-out versus referral ratio. When drop-outs exceed referrals, the practice is in trouble. When referrals exceed drop-outs, the practice is healthy and growing. Changes in trends of these figures serve as signals.

When a patient is dropped from the practice for whatever reason, be sure to make and keep copies of all pertinent records before passing them on to whoever is taking over the case. Court records show that this type of patient is more likely to file a malpractice action than any other patient the office may have treated. A special place in your files should be reserved for such case files.

Use “Address Correction Requested” on the outside of envelopes to assure patients are at the addresses you have in the records. Even if your letter is forwarded, you will never know that the patient has moved unless you use this “ACR” notification on your envelopes.

Handling Complaints and Criticisms

Healing Reactions

During the course of case management, it is not unusual for a few patients to experience new or exaggerated symptoms for a time. These symptoms are often the result of various structural and functional changes occurring during the normalizing process. While the doctor understands this, some patients may feel that the treatment is doing more harm than good. If a patient should mention such a “reaction,” report this to the doctor immediately as the patient may fail to do so. The doctor will then explain to the patient what is happening and put the patient’s fears at ease.

Slow Healing

Sometimes a patient with a chronic condition or long-standing disease process will complain about the slowness of recovery. It must be remembered that a disorder of long duration has been well established and may be characterized by various degenerative processes. Such conditions are often slow in recovery under the best treatment possible. When you become aware of patient discouragement, mention this to the doctor so he may counsel the patient accordingly. Patient discouragement and impatience are traits of the sick that are not difficult to understand. Complaints must be handled with poise, assurance, and empathy. Never treat them lightly.

Family Worries

While family criticisms are rare, they do arise occasionally. This especially occurs when a family member is severely ill or in distress. These criticisms usually come by way of the telephone, and most doctors will want to talk with these people. Some people, however, will impose on the doctor’s time unnecessarily, and it is the CA’s job to use her talents to reassure them without putting them through to the doctor immediately. Remember your feelings when a loved one is critically ill or in pain. Be considerate, but never enter a discussion regarding the patient’s condition and the management of the case.

Symptom-Free vs Optimal Health

The typical patient’s primary concern is to be free of symptoms and assume a normal lifestyle. The doctor’s primary concern is this too, but he is also interested in developing the patient’s state of health to one of maximum resistance to recurrence of the condition. Sometimes the outward symptoms fade rapidly, while a true return to normal or maximum potential may take a much longer period. If the patient has not been educated to the need for extended care, he will have a tendency to quit the outlined program before maximum benefits have been achieved. If you recognize such anxiety within a patient, report this to the doctor so he may explain the facts and possible consequences of premature dismissal.

Whenever you are confronted with a complaint or criticism, be polite, stay calm, keep your voice soft and slow, and maintain a professional poise that is sympathetic with the patient’s viewpoint. Let the patient express himself. Listen carefully; he may be right that a mistake has been made. Listen so you can obtain the facts. Listen between the words to seek a motive or unexpressed concern. Do not argue. When the patient has expressed himself, tactfully review the facts and separate facts from opinions. If you cannot handle the problem, tell the patient you will report the situation to the doctor to see how the problem can be resolved.

Coping with Negative Personalities

While it seems fundamental that the assistant must know how to cope with all types of people and to be helpful, courteous, kind, and considerate, these attributes are often taxed by the grumpy patient. Although most patients are enjoyable to meet, there is always a minority that appear irritable, unreasonable, and sometimes quite rude. Even in such a situation, the assistant must keep her control and composure, and maintain a friendly professional attitude.

Unreasonable Patients

The assistant must realize that the average irritable patient is not being personal. The patient is likely venting his spleen at the person available. Fear, discouragement, pain, fatigue, and anxiety are just a few factors contributing to such a patient’s frame of mind. However, the experienced assistant knows that her cheerful and understanding attitude can do much to calm patients’ fears and enhance a more positive attitude.

The typical reception room has people with varied needs and temperament. While most patients will be easy to relate to, you will occasionally have to cope with the ill-tempered complaining person who will upset the reception area atmosphere. When you see signs of impatience such as fidgeting, fussing, and grouching, be pleasant and reassuring. Always offer a courteous reason the doctor is late if the time is past the appointment schedule. Cranky and whiny children can often be placated with a coloring book or toy.

Irritability and stubbornness are often expressed as the result of fatigue, nervous tension, impatience with a chronic disorder, or worry. The patient may be openly contradictory. However, a CA’s patience, understanding, and soothing personality will do much to calm and reassure the situation. The inconsiderate “trouble maker” who fumes and fusses, is argumentative and often misrepresents the facts, can be handled without argument with poise, patience, and politeness.

Inconsiderate Patients

Inconsiderate “smart alec” patients will tax the assistant’s poise. The “smart alec” is characterized by impatience, intolerance, egotistic and cocksure attitude of self-importance, and difficulty in responding to suggestions. Again, patience, understanding, and a positive sense of humor should be your response.

Indecisive Patients

Both deliberate and indecisive patients require special handling. The slow moving, indecisive, slow thinking, and overly careful patient should be talked with in a slow, deliberate, and clear manner. Instructions must be carefully made point by point, and then reviewed point by point. “Reasons why” must be offered to make instructions logical.

Timid Patients

The timid patient, as the indecisive patient, has difficulty in making up his mind—especially when alternatives are presented. When you talk with this type patient, offer facts and features and place emphasis on the personal benefits involved. Offer messages confidently, clearly, and enthusiastically.

Suspicious Patients

Every office has its share of suspicious, snobbish, and too talkative patients that measure your understanding of human nature. The suspicious patient will doubt the doctor’s judgment, doubt your sincerity, and be cynical of his future. Handle the situation by instilling hope through logical, clear explanations.

Snobbish Patients

Snobs are recognized by their constant attempt to “put down” you, the doctor, the profession, or all healing arts in general. Their slighting remarks and airs of superiority require a rigid professional attitude, firm politeness, and understanding that the snobbish are frequently overcompensating for strong feelings of inferiority within themselves.

Chattering Patients

The patient who babbles endlessly usually does so in sentences without meaning or direction. The habit is, essentially, just a means to release inner tension through self-expression. Be tactful, tolerant, and try to guide the conversation to a meaningful subject by courteously directing and closing conversations. Beware of becoming involved in gossip or rumors. They are favorite subjects of a chattering patient.

Lessons from the World of Business

The doctor is not a businessman, yet the businessman can tell the doctor much about human relations. As the customer is the most important person to the businessman, the patient is the most important person to a doctor. The patient is the purpose of all activity of the practice. Remember that the doctor and his assistants are more dependent on the patient than the patient is on the practice. The patient can go elsewhere and achieve comparable services. The practice is being favored by offering the staff an opportunity to serve. Misguided physicians and assistants sometimes have this truth reversed.

Yes, the business world recognizes the value of its customers. Elaborate systems are maintained to keep in frequent contact with customers, enhance good will, and maintain customer and product loyalty. Business constantly studies the wants and needs of its customers. Business seeks answers to why customers buy or stop buying. Everything possible is done to develop this most valuable asset of any business—the customer.

Control of the Situation

The typical patient entering a doctor’s office seeks help. To help the patient, the doctor must have control in the doctor-patient relationship. This control is founded on a desire to serve the best interests of the patient always. All physical and personality characteristics of the staff should reflect this attitude. If the doctor and his assistants do not understand the desires and needs of a patient, the patient will not be inclined to follow instructions or might be motivated to seek fulfillment elsewhere. The practice not only loses face, it loses an opportunity to serve and ultimately suffers an economic loss. Thus, control is necessary to maintain positive patient relations and safeguard the financial stability of the practice.

CHILDREN IN THE OFFICE

Any chiropractic practice adopting the philosophy of preventive therapy should emphasize the treatment of children, for childhood presents the golden age of prevention. Care during childhood can often foresee serious consequences of apparently slight abnormalities, thus offering the best time to take preventive measures.

The Child Visitor

Besides the child patient, a parent may visit the doctor accompanied by one or more children. Caring for these children when the patent is attended is often the responsibility of an assistant.

The Child Patient

From a human relations viewpoint, children within a practice offer a stabilizing factor. The child patient of today is the adult patient of tomorrow. If cared for intelligently, a child will become a worthy patient. They complain little, are unobservant of minor inefficiencies, do not worry about fees, and are unaware of trifling inconveniences often irritating to adults. In cases where the child is the patient, it the parent who is more often a problem than the child.

The child is preoccupied with self. Cooperation is assured if the child is understood at his level and gentleness, kindness, and patience are offered. The child who likes the doctor and his assistants becomes an automatic booster for the practice. He will tell of his experiences to his immediate family, relatives, school chums, neighbors, and teachers. This is always beneficial to the practice: positive public relations.

The Frightened or Timid Child

The assistant may have to cope with the frightened or timid child. The correct approach to use is determined by the child’s age and temperament. The technique is to put yourself in the child’s place and communicate with the patient in a manner the child understands at the particular age and temperament presented. With any child, you must (1) win confidence, (2) arouse interest, and (3) gain cooperation. Any child, as any adult, is a distinct personality that must be approached according to that person’s nature.

The doctor’s office may arouse fear within the child. The surroundings are new and strange; the people are new and strange; the equipment may be new and strange. The child’s previous experience in a doctor’s office may have resulted in a painful experience or a morbid fear of injections is associated with any doctor’s office. Such fears should never be responded to by glib remarks of reassurance, laughter, or labeling the child a “sissy.” On the other hand, both mother and child should be told what a good patient the child is when the child is cooperative.

The unexpected is as frightening to the typical child as a painful experience. When a child is old enough to comprehend that a procedure may cause some discomfort, they should be told beforehand and an appeal made to their braveness and “grown-up” courage. If you tell a child a procedure will not hurt and it does, confidence will be lost and you will have a difficult time being believed again. Tell the truth, and emphasize how much better the child will feel when he gets better.

Never underestimate the intelligence of the child patient. Children are keen observers, are more intelligent, and absorb much more than adults suspect. This is also true when you are speaking with a parent and you do not think the child is listening. Likewise, do not feel that the child fully understands just because he nods his head up and down in agreement.

The frightened or timid younger child is witnessed by the patient clinging to the parent’s hand and being “dragged” reluctantly from room to room. Such a child, however, is usually quite intelligent and observant of every movement of you and the doctor. Under extreme suspense during examination and therapy, the frightened child will be tense and rigid. Thus, it is necessary at first to spend time to acquaint him with each procedure, explain what will be done and how, tell about the use of instruments to be employed, and win confidence beforehand.

The Bashful Child

The bashful child usually acts in a manner similar to the frightened child exception for not expressing abnormal tenseness. He often holds his mother’s hand in a relaxed manner, expressing a sense of freedom and curiosity while he nuzzles the parent and uses his thumb or a finger as a pacifier. Such children usually adapt to discomfort well when handled kindly and tend to hold back tears if their tolerance is not exceeded. The jovial attitude of others can do much to bring the bashful child out of his “shell.”

The Moody Child

A moody child may fluctuate from cooperativeness at one moment to hostility on another. Such moods usually reflect some casual remark made by some adult, or they may be a method to control the parent by extending or withholding cooperation. The doctor may wish to treat such a child without the presence of a parent or to ignore the situation and proceed as usual without comment.

The Hysterical Child

The assistant usually will not have the training to handle a truly hysterical child. This takes professional training that may require a stern measure. Hysteria may be an effect of fear or used as a psychologic weapon. Parents of a hysterical child should not be permitted in the treatment room.

The Unmanageable or Temperamental Child

The apparent unmanageable or temperamental child is rarely as bad as he may seem on the surface. The attitude usually reflects fears from experiences based more on the child’s imagination than reality. These cases can be handled with gentleness, patience in explanations, and assurance that the patient will not be tricked in some manner. The development of confidence in you and the doctor is primary. This type of child should be treated alone, not in the presence of a parent, where the “chip on the shoulder” has little impression. Children of this nature respond exceptionally well to staff once they are convinced that you mean to do what you have to do and there is no alternative.

Significance of Age Groups

Infant Care

A newborn child presents the least difficulty. If crying cannot be pacified and adult patients appear irritated, the parent should be asked to take the child to a private room until the doctor can see the patient.

During examination and therapy, your assistance may be necessary to support a small baby to prevent the child from squirming from the doctor’s grasp. If the examination or treatment room is drafty or chilly, it may be necessary to wrap the baby in a blanket, exposing only that part necessary for examination or treatment.

Childhood

When the assistant makes appointments for several children on the same day, many doctors feel that the appointments should be grouped if possible. Children appear more cooperative when they are together and not left entirely in an environment of strange adults. However, siblings of the same sex are often jealous of attention, competitive, and restless.

Childhood, which extends from infancy to adolescence, evolves the child from a state of biologic helplessness to that of mature self-dependence. Between these extremes, many changes are witnessed (some normal and some abnormal) in the child’s structural, functional, and emotional development.

About the age of 2 years, the average child begins to understand simple instructions and can often be coaxed into cooperation. Between the ages of 2 and 6, the child’s attention span is short, the body is restless, the mind resists discipline, and contrary acts of will are obvious. Equipment must be guarded as the urge to destroy is common. This period between 2 and 6 years is the most difficult age group to deal with, not only because of the child but because a reprimand may bring resentment from a parent.

After the age of 6, reason can be appealed to according to the child’s intelligence level. During the period between 6 and 12 years, the child develops reasoning and independence that is not so easily placated by a toy or cute comment. Self-interest evolves to a greater interest in the world about him, and curiosity arouses to a greater degree. By communicating with such a child in a serious manner, avoiding deflating attitudes, and handling him in somewhat of an adult manner, security, relaxation, and cooperation of the patient are achieved. Bright children have a tendency to throw tantrums because they are alert to the effectiveness of the weapon. Such a tantrum is not true hysteria; it is an act that requires the doctor’s management.

With the onset of the teen years, both boys and girls often resent having a parent present during consultation, examination, and therapy. The assistant must use great diplomacy in separating child from parent.

Both doctor and assistant must express constant enthusiasm toward the child patient, striving to make the event of the visit a happy occasion rather than a chore. All ethical means should be used to impress the child favorably that he is more than a little person in an adult world. The child must be impressed that you are interested in him as an individual and concerned about his welfare.

Practices handling many children are the least effected by economic trends. The reason for this is that parents want to give their children every possible advantage, even if it takes financial hardship and personal sacrifice. Despite family budget, anything that benefits the child’s welfare is a justifiable expense.

Managing the Child-Patient’s Parents

Parents are important aspects to consider in the care of children. Not only is a parent part of the situation in the office, the parent is involved in the child’s case management, home treatment, and possibly as a factor in the condition under treatment.

Although both parents may accompany a child patient on a visit to the office, it is usually the mother. Either parent can be a great help to the doctor in the child’s case management or the mother or father may be possessive, unreasonable, or blinded to the actual situation at hand. Some-times a child is easily managed in the presence of a parent, sometimes not, and at other times it may be better to allow the child to decide.

The Intruding Parent

When a child is asked to do something, a child’s reaction time between suggestion and action is longer than in the adult even when the child is willing. Sometimes a parent feels she is helping the doctor when she constantly repeats every directive of the doctor to the child. The parent’s constant intrusion at this point of seemingly delayed reaction tends to confuse the child-patient and hinders the doctor-patient relationship.

The parent’s repetition intimates that the child is retarded or has a hearing problem. The same is true in the assistant-patient relationship. If you ask the child to “step on the scale to be weighed,” the parent may follow with, “Billy, step up on the scale” When you ask, “Bill, turn around and face me,” the parent repeats instantly, Turn around dear and face the lady.” In such instances, a tactful, “I believe Billy understands” will usually suffice.

The Overly Sympathetic Parent

The too sympathetic parent can be a problem at times. Such a parent constantly reminds the child that she knows just how much the child is hurting or feeling. The result is magnification of the condition in the child’s mind. Without such reinforcement, the child might be more cooperative. It is easy for a child to become unmanageable when subjected to this constant excessively sympathetic routine. One must be tactful and firm in requesting the parent not to talk to the patient while the child is being examined or treated unless it’s absolutely necessary.

Parent Consultation

The first time a parent calls to make an appointment for a child is the best time for the assistant to state the office’s policy regarding child care. The doctor may first want to see the parent alone on the first visit unless there is an emergency or the child is in pain. If an assistant is not available to tend to the child during the doctor-parent consultation, the parent should be asked to bring another adult with her during the visit.

By interviewing the parent alone, considerable information can be obtained about the child, and the doctor has an opportunity to explain the reasons behind office policy in child care. This tends to relax the parent, condition the parent of what to expect, and gain cooperation from the parent from the beginning.

Parental Communication During Treatment

When children are under treatment, the assistant should be prepared to handle an increased number of telephone calls. Most of these calls can be handled by the assistant once she becomes acquainted with the parents, child’s condition, and treatment plan. It is important for the assistant to discuss this policy with the doctor-employer to determine what questions she should respond and which questions should be referred to the doctor. Frequently, the doctor will prepare a list of questions from which she will question the parent; eg, temperature, pain or distress, breathing difficulty, vomiting, diarrhea, and last meal?

Mothers often like to discuss with the assistant home treatment prescribed by the doctor. They may feel that another women’s viewpoint will help to clear their understanding. If the assistant is familiar with the instructions, she should explain in untechnical terms and/or provide printed instructions approved by the doctor.

History Taking and Its Rationale

If it is the duty of the assistant to take a portion of the history, details should be listed regarding the child-patient’s eating habits (including the amount of sweets and soft drinks), sleeping habits, recreation and exercise habits, and general behavior and temperament. Avoid vague and generalized answers.

In recording a child’s history, data concerning development and past illnesses and disorders are important. Those conditions having adversely affected normal growth and development constitute the developmental history. Severe vitamin deficiencies (eg, rickets), endocrine disorders (eg, hypo- or hyper-thyroidism), and metabolic disorders may have an effect on skeletal growth and muscular function. The age of occurrence of such disorders is important to record. The age of walking and teething also should be noted.

A record of the child’s present and past health status represents the medical history. The parent should be questioned regarding the child’s birth, the pregnancy in general, labor abnormalities, and whether instruments were used during delivery. Such childhood diseases as diphtheria, scarlet fever, measles, rheumatic fever, rickets, typhoid, allergies, etc, should be recorded accurately and in detail, along with unusual weight gain or loss. Special concern should be given to any spinal condition, past or present. Questions concerning abnormal shoe wear, irritability, manner of walking, frequency of headaches, general behavior, and “growing pains” are also significant.

Mensuration

Most growth normally occurs in three cycles classified as the infantile period (in utero to 2 years), the juvenile period (from 8 to 11 years), and the adolescent period (from 13 to 17 years). Normal growth within any of these periods may be influenced by under- or over-nutrition, disease, or trauma.

Structural growth, usually measured by standing height and limb measurements, does not occur in an uninterrupted, smooth, even, bilateral manner. Both the body as a whole and its individual parts go through periods characterized by acceleration and retardation.

The doctor may ask the assistant to take several measurements of the child-patient. In general, the length of the extremities from the sole of the foot to the pubis should be approximately three-eights of total body length during normal infancy. This relationship gradually changes with age until the pubis is approximately at the midpoint of the total length of the body. Structural measurements should always be taken bilaterally when extremities are measured. The information gathered is important in disorders of the extremities, especially those involving the epiphyses.

The Initial Examination

After the doctor reviews and enhances the history taken by the assistant, an examination will be scheduled. The examination of a child and that of an adult is similar except for age factors. The doctor’s observation faculties must be much greater, however, as the child has more difficulty in expressing subjective feelings or describing an accurate picture of a complaint.

Office Rules and Procedures

Special rules and procedures must be established within the practice if child care is to be incorporated and made pleasant, efficient, and profitable. Several aids are explained below:

Special Hours

Special hours on certain days can be reserved for the treatment of children. They will feel more at home in the presence of other children. From a public relations standpoint, the grouping also educates other parents of the need for chiropractic care for all children of all ages. As children appear to be more cooperative in the morning, the best hours for scheduling younger children are from 9:30 to 11:30 am. Printed excuses can be used to schedule high school students during school hours.

Special Attitude

A special attitude is necessary in the care of children from the moment the child enters the reception room to the time of dismissal. The behavior of both assistant and doctor is largely reflected in the child’s attitude. Every impression instilled during points of contact is important. Each procedure offered must be carefully limited to the capacity of the child’s tolerance.

While almost everybody appreciates and remembers kindness and friendliness, children tend to do so more than adults. Children in the office are little strangers, afraid of a world they never made. By nature, they are apprehensive of changes in routine procedures, thus consistency is important. At the same time, children will usually take to new procedures more rapidly than adults if a change is explained and care is taken to develop their enthusiasm. As with adults, the most important factor before beginning any procedure is to get the patient relaxed and in a receptive frame of mind. Any professional method that attains patient relaxation is well worth the effort.

Preconditioning

It is often a good policy to have the assistant spend some time with the child patient before entrance of the doctor. An understanding assistant can do much to ease the child’s fear and develop confidence in the doctor to enhance an excellent doctor-patient relationship. If an assistant asks the child about his hobbies, interests, likes and dislikes, answers questions about equipment and procedures, and reassures the child that there is nothing to fear, the child is conditioned to accept the whole procedure as a pleasant experience and will be receptive to the doctor when introduced. Such attention flatters the child’s ego and makes him feel as a VlP. He will be more relaxed, more suggestible, and more responsive to the doctor’s presence. Confidence and cooperation will be almost assured.

Testing

Certain tests must be given to children just as they are to adults. The need for one’s imagination when dealing with children is obvious. As children have a tendency to get excited, it is important to calm them before testing. For this reason, basal metabolism tests on youngsters under 6 years of age are rarely accurate. It is helpful with young children to divert their attention and calm them by telling them a story or make a game of the procedure. The mouthpiece of a BMR instrument, for example, can he likened to the oxygen mask of a space ship.

Home Safety Instruction

It is important that the assistant help the doctor in teaching safety measures when a parent is in the office. All parents should be warned to keep medicine out of the reach of children, flush old medicines down the toilet, and practice good safety habits in the home. Young children should be taught to avoid matches, gas stoves, electric appliances, cleaning fluids, poisons and pesticides, slippery surfaces, and climbing on ladders and trees. The safe use of sharp instruments such as scissors and knives should be taught. Once older children are taught the proper use of such things, they no longer need be hidden.

Office Safety

The assistant must be constantly aware of safety measures so that accident prevention is primary. Cautionary vigilance is imperative. Children should never be left in a room alone. Their imagination can become so overactive that it results in mischief. The doctor should summon the assistant if a child must be left in a room and a parent is not present. One should not be surprised when a child, who is not sufficiently matured, reacts to animal instincts.

When an unsupervised child gives vent to inherited traits, such actions must be understood by the assistant and reacted to with calmness and understanding. With small tots, toys are often important. 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 clean stuffed animals, and animated picture books are common choices.

Scheduling Control

The doctor of chiropractic may accept many cases of behavior disorders such as retardation, hyperkinesia, severe nervousness, or children with temper tantrums or tics. Thus it is important that waiting time be held at a minimum. This requires alert scheduling. If the patient is late, time from the appointment reservation must be deducted so that the next appointment can be taken on time with a minimum of waiting. Waiting adds to tension. Kindness, special consideration, and efficiency are essential in such case management. To reduce waiting time to a minimum, try to have everything possible in readiness beforehand. If waiting is unavoidable, children love to hear stories. Learn to be a good story teller.

Periodic Check-Ups

In most practices, children will be scheduled for check-ups before vacations, camps, and supervised sports, and before school opens. Because these appointments will be likely made in June and August, the assistant in charge of scheduling must anticipate time for these children.

Confidential Information

The law also protects clinical data of a minor from all but a parent or guardian. Overdoting relatives may telephone and inquire about a child’s health. Never release any information without the consent of the parent or guardian. Refer all inquiries to the parent or guardian.

Third-Party Forms

Schools and camps may require certain forms to be completed. The assistant will usually fill these forms out for the doctor’s signature. If a vaccination history is required, this must be reported by the parent to a MD or DO.

Building Positive Relationships with Children

When a child’s enthusiasm is properly cultivated and stimulated, the child can do much to the indirect education of parents, friends, relatives, and acquaintances to the value of chiropractic services. To develop this state of mind, several factors should be considered. Following are some thoughts to enlist in developing better cooperation of both child patient and parent.

Self-Image Development

Children love flattery regardless of their age. Boys like to hear that they are brave, have good bodies, and can be an athletic champion if they work at it. Girls like to be complimented on their beauty, form, dress, and potential ability to become wonderful dancers, ballerinas, and attractive to boys. Flattery helps to solidify the office-patient relationship.

Remember that better results are obtained and a closer relationship can be established in many instances if parents of an older child patient are excluded from the examining and treatment rooms. Nothing will yield better dividends in health care than gaining the patient’s confidence and satisfaction by minimizing fears and anxieties.

Communication

A child should be spoken with at his level of understanding and recognized as a unique individual. Speak to the child as much as possible in an adult manner so that his consciousness will be raised rather than relating to him as a “mere child.” At the same time, never exceed the child’s level too much. Stoop when you speak so that you are at the same head level, eliminating the image of a very large and overpowering person.

When special instructions are given to the child to execute outside the office, instructions should be given directly to the child (if he can comprehend) in the presence of a parent. This flatters the ego of the child who then feels important and responsible. The presence of the parent offers third party assistance if recall is necessary.

Avoid giving a direct command to a child or using a paternal attitude. It may arouse opposition as the child gets enough of this at home and school. By putting your instructions in the form of a request or suggestion, the child will more happily comply with what you desire.

Both doctor and assistant should choose their words carefully in communicating to children who do not quite understand their meaning. Words such as manipulation, regulate, disciplines, and other technical jargon often stir the imagination to fearful anticipations. Never discuss details of techniques or procedures in front of the child-patient. The doctor will only discuss a child’s unfavorable prognosis with a parent in private. Any child’s questions should be answered honestly in terms the child can comprehend. While unpleasant details can be minimized, a good relationship will be broken if the child learns he has been lied to or tricked.

High-quality educational material geared to the child’s level should be in the reception room, just as it should be for the adult level. The ACA has an excellent coloring book and several pieces of child-oriented literature available.

Special Attention Pays Dividends in Human Relations

Most doctors will not treat a child patient with a chronic condition on the first visit or he will only offer a simple prophylactic therapy. This allows the child time to evaluate the office, staff, and surroundings and arrive at the conclusion there is nothing to worry about. Much can be accomplished during the first visit if nothing more is done but to wean the child from his worries, fears, tensions, and apprehensions. Winning of confidence is the goal. When the child leaves the office smiling, a good relationship is assured.

Special recognition is deeply appreciated by a child. It is good policy to record birth dates and send a card in remembrance. Send children a special valentine from the doctor and staff. Offer companionship to the older child patient showing you appreciate the patient’s intelligence and maturity by, within reason, liking things he likes and not liking things he does not like. Show interest in the child’s skills and hobbies, and note these in the patient’s records as a reminder.

It is policy in many offices that every new young child patient be given some sort of gift when he leaves the office for the first time; eg, a balloon, set of crayons, coloring book, rubber ball, or 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 value of the gift as it is the instilling in the child that you feel he is someone special.

When children are frequent visitors to the 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 the 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.

Children take their play very seriously, but sometimes you may have to take the time to point out certain possibilities. Give the child only one toy at a time. Once he tires of it, give him another. A “kiddie korner” equipped with a small table and chairs can be adapted within a 4-ft by 4-ft space in almost every reception room if many children are cared for in the practice. Such space makes small children feel at home, minimizes disciplinary problems, and alerts the casual adult patient that the practice is concerned with the health care of children.

While relationships with child patients 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. Be friendly in a reserved manner. Children are not adults, thus they must always be understood and handled as children.

THE ELDERLY IN THE OFFICE

Because of the high incidence of degenerative musculoskeletal diseases, elderly patients are seen in chiropractic offices far more than children. As with the very young, the very old require more time, patience, assistance, and closer attention.

Age Considerations

The process of aging begins at birth and stops only with death. It is a gradual process. Changes occur in a fairly predictable pattern, but the rate of change varies from one individual to another. Old age is a period often marked by mental confusion and vagueness, and this must be considered in extending aid. Chronological age, however, does not make a person young or old. Some people are young in spirit and alert mentally at 90 years and others are old at 25 years. The chronological age of 65, however, is arbitrarily considered the dividing line point between middle age and old age.

Special Human Relations Considerations

As a group, the elderly tend to be talkative yet secretive, and sometimes hostile, rude, and childish, but their remarks should not be taken personally. Most of their hostility comes just from the resentment of the effects of growing old.

Assistant Maturity

Attendants should be nonjudgmental, stable, and even-tempered—attributes known as maturity. A mature assistant will possess self-respect and pass this respect to others through kindness, tolerance, and patience for the elderly. Sincere interest and gentleness is deeply appreciated. However, old people detest and are quick to recognize insincerity. Communicate slowly and distinctively without appearing patronizing.

Schedule Logically

An elderly patient usually will take more time than a young adult. The appointment assistant should be aware of this and schedule accordingly. Do not rush elderly patients. As mentioned, it will injure their self-esteem.

Develop Empathy

Probably the most important attribute necessary in caring for the elderly is empathy. This takes a projection of one’s personality into the problems and personality of another person. It takes imagination. For example, imagine that you are a person who has lost your job, lost most of your friends, lost a part of your hearing and vision, lost many of your teeth, lost your ability to speak fluently and decide quickly, and lost much of your health and pride. Then replace these losses with new pains, stiff joints, a slumped posture, circulatory deficiencies, constipation, and the embarrassment of being unable to do simple tasks and remember a recent conversation. If you can imagine this and appreciate the feelings involved, you will have empathy for the elderly. It is no wonder that their insecurity is often expressed as hostility.

Preserve Pride

It will often seem easier and quicker to do something for the elderly patient rather than let him do it for himself because it takes him so long. However, oversolicitousness will force him into a dependent role —a role he does not want and one that is incompatible with a healthy outlook on life. Avoid the temptation to “take over.” The aim of proper assistance is to permit the patient to do as much for himself as he can, with only a minimum of assistance. His small accomplishments will mean much to him. Help patients to help themselves, and always ask if assistance would be helpful before giving it. Most elderly people guard their independence. Respect this.

Special Considerations of Trauma

Age is often a distinct factor in many musculoskeletal injuries. As a group, older people are susceptible to fractures. Their vision and hearing may be impaired, increasing the possibilities of accidents. Atrophy of bone and connective tissue occurring as part of the aging process may also increase susceptibility to fracture, sprain, and strain. Additionally, the elderly may be poorly nourished, poorly coordinated, have a decline in postural stability, and have difficulty walking. With advanced aging, one’s level of proficiency progressively deteriorates.

Senior citizens may have disorders predisposing to a variety of complicating disorders; eg, cerebral ischemia, osteoporosis, arthritis, postural hypotension, weakness, and neurologic disorders that affect locomotion. While such disorders predispose a person of any age to injury, the elderly are particularly at risk because of concomitant factors that accompany advanced age.

Musculoskeletal injuries of the elderly range in severity from relatively minor soft-tissue injuries to severe crushing fractures. Older females are especially prone to fractures. Males, as a group, most commonly sustain fractures in their younger years, up to the age near 45.

ADDING THE PERSONAL TOUCH

It has been emphasized throughout this program that any individual who is sick, in pain, or worried must be dealt with in an atmosphere of understanding and consideration. When health is lost, a sense of security is lost, and that person is operating on the motivation level of self-preservation and threatened personal safety.

A Review of Fundamentals

While the doctor’s diagnostic and therapeutic skills help to restore confidence and relieve some patient stress, a strictly scientific approach is not enough. The patient’s emotions and frame of mind also must be considered. The patient looks to the doctor and staff for friendship, understanding, and recognition as a special human being rather than a case. The state of rapport between patient and office staff can be as important as the technical service.

Office staff should at every opportunity be kind and empathetic to every patient. Sincere interest in the patient and the patient’s problems should be expressed. Remember that the apprehensive new patient to the office enters new surroundings, experiences odors from antiseptics, sees strange looking equipment, and confronts new personalities with which to cope. There are many fears and anxieties about fees, what the doctor may do or recommend, debts, and loss of income from your services. Without proper understanding, an assistant may view such patients as “difficult,” yet it is not abnormal if a patient should appear nervous and irritable.

While a patient’s feelings may be held from the doctor’s view, they are often openly expressed to an assistant. The assistant, however, should never take this personal. The patient is only “letting off steam” from an internal “boiler” the best way he can at the moment. By establishing a pleasant relationship from the start, by obtaining friendly cooperation, by being patient without condescension, and by avoiding anything that would contribute to increased patient tension, the assistant is far ahead in establishing positive patient relations.

A competent physician, a spotless office, and shiny equipment are not substitutes for kindness, friendliness, personal interest from the doctor and his staff. To the patient, there is just one patient that counts despite the volume of patients that must be seen. Sometimes all that is needed is a smile and friendly remark and a feeling that he is not being hurried in one door and out the other.

Patients appreciate the personal touch. As the doctor rarely has the time, a telephone call from an assistant to discuss progress is always appreciated, but it must have the doctor’s permission. Good scheduling avoiding prolonged waiting time is also appreciated for its shows respect for the patient’s time. Thus, delays should be explained with regret.

As unfortunate patients may visit the doctor, the assistant should be careful not to display revulsion, antagonism, or condescending airs to those who are disfigured, maimed, scarred, or handicapped; those with tic, spastic tremors, parkinsonian movements; or those with ugly skin conditions. Nor should these afflictions be ignored. The patient knows his condition, and so do you. Do not make believe that the patient is not what he is. This is unrealistic and not appreciated. Hold a positive attitude, radiate confidence, build good cheer, be optimistic, and the patient will too.

This positive attitude does not erase the fact that there will be problem patients. Some will be chronically late or tardy, some uncooperative, some fail to follow instructions, some will use crude language, and some will unfairly criticize the practice and its procedures and policies. Remain professionally firm and tactful in such instances. Despite experiences, each patient should be greeted with a smile on entering and leaving the office. The patient should leave with the feeling that the visit was important, he or she is important, and the scheduled return visit is important.

Patients appreciate “extra” services beyond expected technical services. Service organizations go to great extent to offer their clientele extra but highly important auxiliary services. In the personalized chiropractic office, these extra services may be home-therapy equipment as braces available for loan, a lending library, bus schedules, travel tips, a simple beverage while waiting, placing a call for a taxi, or some other “extra” service.

The Role of Office Records

All offices should maintain accurate and comprehensive clinical and financial records. As all patients are different and present different variations in disorders, such records serve to provide better health service. But if we wish to serve the total person, there is a need to custom-design technical services to be harmonious with patient’s emotional needs.

When office records also incorporate personal data about each patient such as special interests, hobbies, likes and dislikes, aspirations, etc, doctor and assistant are more able to speak “in the patient’s language.” The power of persuasion will be increased many fold when you know how to explain office procedures and policies in terms of patient interests.

Personal Public Relations

As a representative of the office, every contact between you and a patient within the office and every contact between you and a person outside the office subtly affects the doctor’s reputation. Negative attitudes on your part discourage patients from returning and discourage others from entering the practice. The assistant who constantly creates good will wherever she goes is a distinct practice builder. Everyone likes the friendly, sympathetic, pleasant assistant who is truly interested in people as individuals. This interest is shown by remembering people by name; by being interested in their children, work, and hobbies; and by being a good listener.

The Art of Communication

The more you know about a patient without appearing inquisitive, the more effectively you can communicate with that person. The person’s home address, clothing, posture, car, gestures and other body language, occupation, hobbies, and educational background can tell you much. By listening carefully to what the patient talks about, you can become alert to his likes, dislikes, worries, self-image, pride, and aspirations. You can soon learn how the person arrives at a decision, how he reacts to a motivational block, and what “special interests” he reveals only to those whom he feels close. Knowing such things allows “personalization” of the approach. You will then be able to explain complicated subjects by using analogies meaningful to the patient. You can draw parallels that ease tensions and develop inspiration.

If you listen carefully to the patient, you will be able to use the patient’s key words in feedback to convey you understand what the patient feels and means to say. By paraphrasing the patient’s words, you also will be able to instruct the patient in terms he will understand. This act serves to reinforce rapport, enhance the patient’s ego in that you “talk the same language,” and invite the patient to drop some communication defenses because you have proved you were closely paying attention and are interested.

This is not a new technique: it has long been used by successful salesmen, marketing experts, and others. In the June 1965 issue of Reader’s Digest within an article titled “The Delicate Art of Asking Questions,” John K. Langemann states:

There is a powerful tool that 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 all expressions of feeling, however faint or fleeting. In statements that begin “I feel,” “I wish,” or “I don’t care if….,” the interviewer acknowledges, perhaps by repeating their content. Or he may just note, “You feel very strongly about that, don’t you?” or “Is that so?” Having 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.

Appealing to a Patient’s Inner Needs

Positive relations based on a sound understanding of human nature has both clinical and economic benefits. It has been proven that a patient with a positive attitude will heal quicker than one with a negative attitude. On the other hand, a positive mental attitude in the doctor and assistant enhances the effect of professional skill. From a practice standpoint, it keeps established patients associated with the practice and encourages referrals that attract new patients to the practice.

Because there undoubtedly will be equally competent and equipped offices in your area, it will be human relations factors that differentiate your office from another. It will be human relations factors that determine which practice patients enter, remain, and boost. Competent health service can be found somewhere; special humanized service is more difficult to find. People will go where their thirst for personalized attention can be satisfied to some degree when other factors are equal. Many doctors and assistants virtually force some patients out of the practice simply by failing to nourish emotional hungers.

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

Just as a business having 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.

During the initial interview, you may learn that a patient has been switching from one practice to another for the same condition. This is a clue that emotional needs went begging. The reasons offered will be endless, but rarely will they be the true reason for changing from doctor to doctor. Here are some thoughts that probably enter the patient’s mind many times:

— “I was kept waiting for long periods. My time was considered unimportant.”

— “I was treated like a child.”

— “I was hurried here and there, and nobody had the time to listen to me.”

— “I was just another case to them.”

— “I was criticized when I suggested a second opinion from a specialist.”

— “I couldn’t understand what they were doing or why they wanted to do it.

— “They talked in highly technical language.”

— “My complaints were belittled and made light of.”

— “I wasn’t a human being to them. I was the 2 o’clock insurance whiplash.”

— “They played favorites, and I found this insulting.”

If we analyze these complaints carefully, we come to one conclusion. All the reasons listed involve insults to the patient’s ego. They all said in unspoken words, “You don’t count” or “You’re not important.”

Several years ago before the Conference of TransCanada Medical Plans, Dr. Ernest Dichter reported on the conclusions of his motivational studies in business and the professions. One of his statements is pertinent to this topic:

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 all the medical equipment, medical knowledge and drugs were developing at an ever-increasing rate, the human aspect in the doctor-patient relationship had fallen behind. A psychological lag had taken place ….

Fortunately, the chiropractic profession did not fall into this psychologic lag as has the allopathic profession. This is probably because the “human touch” is an integral part of chiropractic therapy and chiropractic has emphasized concern for the total individual.

Chiropractic physicians and their assistants have learned the importance of applying scientific know-how with positive human relations. They take the time to establish a personal rapport with each patient before giving impersonal instructions. The patient is given concentrated, undivided attention. People are truly listened to and professionally “catered.” Patients are escorted in their choices rather than directed.

The humanized chiropractic practice offers an abundance of “special” services and “extra” favors. The doctor directly makes referral appointments with specialists showing personalized concern. A patient’s complaint or question is never made light of or belittled. Even if an assistant may be responsible for the administration of a procedure or therapy on a particular visit, the patient should never leave the office without visiting with the doctor.

Printed instructions should be preceded by oral explanation. Literature should be considered “reminders,” not “recipes.” If time permits, personalized typewritten instructions are better for they signal, “This is especially for you.” In this regard, Robert Levoy in The Successful Professional Practice refers to Les Giblins’ remark that “No girl likes to receive a carbon-copied love letter.”

Resolving and Preventing Complaints

A pessimist will react to a complaint as a personal put-down, while an optimist will react to a complaint as an opportunity for self-analysis. Some doctors and assistants think they live in a type of ivory tower because of their specialized training. Complaints are considered insults because they believe that patients do not have the right to complain. Yet these same professionals will take their car to a garage and tell the mechanic to “Change the oil, check the plugs and points, and repair the flat in the trunk.” Most people would become highly indignant if the mechanic answered, “Don’t tell me how to do my job. I know more about automobiles than you do. I was certified as a top mechanic in one of the best trade schools and have been working in this field for 25 years.” Would not these professionals think, “But it’s my car?”

When a person seeks service, even health service, he takes for granted that the agency has personnel that are competent and qualified. This does not mean that customers or patients do not have the right to ask questions, complain when they think service is below standard, or believe an oversight or error has been made. In fact, questions begging answers mean a person is interested. Disinterest is shown by the person who stops talking, becomes withdrawn. Thus, complaints and questions should not be reacted to as affronts to ability. When your reactions are negative, more complaints, questions, and objections are created.

There are many reasons why a patient may object, question, or complain. It is important that both doctor and his assistants be prepared to respond in a professional, human, personalized manner. Here are a few examples:

1. People need facts to support their position. Chiropractic is a minority profession. It is probably the least understood healing art of the three major health provider groups. Because of this, a patient’s neighbors, friends, relatives, or coworkers may not think the patient is doing the right thing by entering the practice. When a patient is exposed to negative comments and doubts, the patient needs answers to questions and concerns eased to defend his position against those who do not understand.

2. People need to know what is being done and why it is being done. Many chiropractic procedures are new to the patient. Apprehension is not unusual when a person is placed in a situation that is strange. Fear of the unknown is one of our greatest fears. Because we are unfamiliar, we fear making errors spotlighting our ignorance that would subject us to ridicule. Thus, it’s normal that a person exposed to new ideas and “different” procedures will ask questions to gain a clear understanding of who, what, when, where, and why. Thus, avoid becoming irritated when even simple instructions are asked to be repeated.

3. People need conflicting thoughts resolved. When conflict is not solved, anxiety results. Patient questions indicate a strong need for reassurance. They need reassurance that the x-ray films recommended are not dangerous as an article stated in some magazine. They need reassurance that a remark made by another doctor many years ago to the effect “Chiropractic treatments may be harmful” is not true. They need reassurance that “deep heat” will not cause pain. Many patients realize that the doctor has gone to a great deal of trouble in consultation and examination to arrive at a differential diagnosis and recommend a treatment plan. The more “well read” the patient is, the more there is need to clarify misunderstandings, hearsay, and half-truths. A patient with conflicting thoughts is not usually seeking an alternative to the doctor’s recommendations. He is seeking answers to why his generalized beliefs are not true in his particular case.

4. People need adequate justification for their acts. Gestalt psychology emphasizes that people really do not know why they act the way they do. Although we make a choice consciously, this conscious selection is based on many deeply subconscious beliefs (some rational, some not), conditioned reflexes, programmed responses, and fixed behavioral patterns of which we are unaware on the intellectual level of consciousness. While we may be aware how we feel, we are unable to know exactly why we feel this way. Thus, we must rationalize actions. When we want a new car or a new dress or suit, we buy it. We rationalize our action in terms of “good quality,” “will last a long time,” “a good investment,” “cheaper than repairing the old one,” and other conscious justifications. Subconscious urges for status, selfishness, self-indulgence, ego gratification, etc are repressed from conscious awareness for they would surely result in painful guilt and prevent us from having what we want. Therefore, when a diagnostic or therapeutic procedure is recommended or a treatment plan is prescribed, the patient’s investment in time, money, and effort must be justified in harmony with personally acceptable criteria. Quality health care “eases pain and discomfort,” “safeguards against income loss,” “enhances personal performance,” “improves resistance,” and so forth.

5. People need their priorities put in proper prospective. Most people have fixed sources of income, and their wants often exceed their means. We want a nice car, a comfortable home, attractive clothes, a swimming pool, exotic vacations, good education for our children, and the other good things in life. But these things are meaningless if we do not have our health. Thus, patients must be shown and convinced that health care is the priority consideration. They must be persuaded at times that professional services should not be postponed until “the patio is completed,” “the Christmas bonus comes in,” or “until the new business gets off the ground.” Such excuses may seem highly irrelevant to those of us who work in health care, but they are not to the average patient. The patient must be continually educated, persuaded, and convinced of the value and benefits of professional services. This takes explanation, illustration, demonstration, and a large degree of “salesmanship” sometimes so the patient will want health care more than anything else. To nurture this frame of mind, the patient must be shown that the doctor’s professional services are a means to achieve and appreciate other wants, goals, and needs. Health care is not an alternative to or an obstacle in the path of a patient’s personal goal attainment.

6. People need their self-concept reinforced. It is often said that the profession of chiropractic reached its present status solely because it achieved results in cases where traditional health-care methods failed. There is much truth in this as the average person, habitually programmed by social forces, will risk deviating from the established pattern only when all conventional avenues have become exhausted and desperation forces consideration of the irregular. Thus, many patients new to chiropractic health care are apprehensive. This tension can be relieved by showing the patient that their selection was the right one. It can be brought out that great sports figures like quarter-miler Ken Randle, discus-thrower Mac Williams, and high-jumper Dwight Stones attribute much of their success to chiropractic. You may mention that Rocky Marciano and Mohammed Ali called for chiropractic care frequently, as have several professional golfers such as Arnold Palmer, many professional baseball players (including Babe Ruth), and four-time bowler of the year, Earl Anthony. John D. Rockerfeller, Sr. and Hubert Humphrey were chiropractic supporters. Many famous past and present actors and actresses such as John Wayne, Bob Cummings, Jane Fonda, Carol Lawrence, Robert Goulet, to name a few of hundreds of celebrates, have been chiropractic patients. These famous personalities could afford the best, and they chose chiropractic care.

7. People need to disguise their unfulfilled emotional needs. Chronic complainers will not openly admit that the doctor or assistant is not fulfilling their needs for friendship, warmth, or reassurance to the degree expected. No, they disguise their disappointment by faultfinding, irritability, uncooperativeness, ignoring statements, and other methods “to get back at you.” The patient who complains about almost everything is really trying to express dissatisfaction with the interpersonal relationship. Look for the reason such a patient feels insulted, ignored, belittled, or angered. Patient irritability, sulking, pouting, and other behavioral changes are signals that there has been some breakdown in positive human relations that needs immediate repair.

Throughout your career, review these seven points frequently. You will find them not only helpful in your relationships with patients, but also in your relationship with any person who complains about something with which you are associated. Naturally, some complaints from the patient’s viewpoint have a logical rather than an emotional basis such as an error in a bill or exceedingly long waiting periods. Most complaints, however, will reflect other motives. In summary:

— People need facts to support their position.

— People need to know what is being done and why it is being done.

— People need conflicting thoughts resolved.

— People need adequate justification for their acts.

— People need their priorities put in proper prospective.

— People need their self-concept reinforced.

— People need to disguise their unfulfilled emotional needs.

The public is becoming more critical of health-care practitioners each year, but this is not a new phenomenon. It has been growing for several years but only recognized by the most alert health-care personnel. The criticism is not technology oriented, it is human-relations oriented. As far back as December 1955, E. L. Koos, PhD, brought this out in an article titled “Metropolis, What City People Think of Their Medical Services,” which was published in the American Journal of Public Health and copyrighted by the American Public Health Association, Inc. The article told of a study of 1000 families selected at random in a city of 350,000. Dr. Koos reported:

1. There was almost no criticism of technical competence.

2. Only 19% thought health care cost too much.

3. As many as 47% criticized the physician’s handling of his practice.

4. The greatest criticism involved the doctor-patient relationship:

Sixty-four percent of the replies indicated that modern, technic-centered medical practice lacked the human warmth of the old-time general practitioner (who possibly knew less about medicine, but more about his patients). Those who are defensive regarding criticisms of modern medical care have been known to charge that this attitude exists only among the older age groups who view the passing of the family doctor with nostalgia. Our data do not bear this out, for the respondents in the families with husbands under 40 years of age were even more definite in this criticism than were those in the older age group…. We can probably best sum up the position of the people of “Metropolis” regarding their medical care in these words: they tend to be satisfied with what they get and to accept its cost, but they dislike the way it is provided.

An assistant who has little knowledge of human nature tends to turn a deaf ear to complaints, while the trained assistant knows how to turn a complaint into an affirmation. The experienced assistant knows that a questioning patient is an interested patient, a participating patient, a person seeking answers who wants to be a good patient but needs help.

The Art of Gentle Persuasion

A good salesman will tell you that it is almost impossible to sell a person who says, “I agree with everything you say, but I don’t want it.” On the other hand, the average person will put up various specific reasons for not purchasing (objections, complaints, excuses). The good salesman will have a ready answer for each objection, knowing that when all objections are answered, the person is in a position where he must buy because his reasons for not buying have been erased through explanation, illustration, demonstration, and agreement with advantages of features and benefits. To understand this is to understand the gentle art of tough-minded persuasion.

Whenever the alert salesman is presented with a new objection he does not have a ready answer, he writes it down and later thinks of a good reply if the objection should ever be raised again. Health-care personnel can learn a lesson from this practice as most complaints are universal among the health-care field. When the same complaint becomes common, it is an indication that the subject matter has not been properly covered within the patient’s orientation to the practice’s procedures and policies.

There are several methods by which the assistant can be taught or learn from experience to cope with general patient complaints and turn dissatisfaction into inspiration. A few are listed below:

1. If a patient asks a question that is difficult to answer, rephrase the question into one you can answer. If a patient should ask, for example, “Why are the doctor’s fees so high,” you could respond, “If I understand you correctly Mrs. Brown, you’re asking if the doctor’s fees are unusual for these types of services. I can assure you that Dr. Smith is very careful in seeing to it that his fees are based on those usual and customary throughout the community for identical services.” Such a response to a patient’s inquiry tells the patient that you were listening attentively, showed friendly respect in answering the question, but had to put their inquiry into proper prospective.

2. Inexperienced assistants have a tendency to anticipate a complaint and attempt to answer it before it is fully given. This is an error, for a patient may feel the interruption is a “brush off.” It may be interpreted as “I don’t want to hear you. I know what’s best for you.” When you refuse to listen attentively, you are telling patients you do not care, are not concerned, and have more important things to do than bother with them.

3. Third-party testimony avoids being placed between a patient and his goal or a conflict in personalities. This is done by prefacing your answer with such phrases as “According to national statistics,” “Health-care surveys indicate that….,” or “The latest figures state that….” For instance, if a patient should criticize the fact that the practice does not have evening hours, you might reply, “According to a recent national survey, most patients prefer daytime hours so they can spend evenings with their families and friends.” By so doing, you divert the patient’s complaint to the statistics and benefits rather than office policy. Never try to prove that you are right. Let figures and statistics do that. It’s always better to say, “It has been found that….,” rather than, “Our policy is ….”

4. Avoid answering a direct question with a curt “yes” or “no.” Remember that more is at stake from a human-relations standpoint than an answer to a question. If a patient should ask, “Isn’t it true that…?,” offer a “yes—but” reply. In other words, agree and then disagree. For example, “I felt that way once until I learned that…,” “Many people think that, but the majority feel…,” “What you say is certainly true sometimes, however…,” “I can understand your viewpoint, but recent evidence indicates….” The patient must be handled as an intelligent person who has some slight misunderstanding. His complaint or question should be accepted as a logical occurrence from the individual’s viewpoint. If he is in error, it’s not his fault that his information was incomplete or inaccurate.

By being aware of reasons a patient may object, question, or complain, the assistant is in a better position to resolve and prevent poor human relations. Once the assistant masters the art of coping with complaints in a friendly manner, dissatisfaction can be converted into inspiration. The basic key to successful problem solving in the office is to be on the patient’s side. Never appear to be an antagonist or a block to a patient’s goal. This would be a “no-win” position.

Filling the Communications Gap

Self-preservation is one of our most basic urges. When we feel our health is threatened, we call on all our energies to return us to as normal as possible. Anyone who will help us has our respect. Any information that will help is appreciated. However, while the typical patient will crave for the whys and wherefores of his illness and treatment, he is also often 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 solution as the related anxiety still burns.

Answering Silent Concerns

When John Smith is ill, he wants to know why he is sick, what can be done to return his health, and how he can prevent the disorder from returning once it has been seemingly corrected. 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 and how much it will cost; and answers to many other associated questions. He begs for answers even if he does not ask questions. He wants to understand. He wants a simple explanation, not Latin or Greek mumbo-jumbo. He wants his confidence built up, not his intelligence put down.

The patient needs and deserves an explanation. When a 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 the explanation in a simple step-by-step manner that he can understand. He wants you and the doctor to explain what you are doing and why you are doing it before you do it. He wants you to vocalize the features and benefits of each of your actions. Always remember that many routine things you do are not routine to the patient. What may be obvious to you may be confusing or fearful to the patient.

Health care is a learning situation. Time and again it can be shown that the best-informed patient is the most motivated patient; the least-informed patient, the most uncooperative. We should be alert, however, to recognize that effective communication does not depend on how much is explained to the patient but on how the patient interprets what is said. A doctor or assistant may offer a “technically correct” explanation that is completely misinterpreted by a patient. Patient feedback is the best method to determine proper interpretation. Misinterpretation results when we take for granted the patient understands.

Leverage Through Illustrations

Offering a simple verbal explanation does not guarantee learning. While we learn through our senses, behavioral scientists tell us we learn only about 10% by what we hear, a large 85% by what we see, and about 5% through the senses of taste, touch, and smell. Thus, telling is far inferior to showing. Comprehension and recall are greatly enhanced when we use visual aids; eg, models, charts, pictures, graphs, drawings, demonstrations, and dramatizations.

This shows the advantage quality patient literature has on enhancing patient education. It reinforces 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 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 authority to what has been explained.

While most 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 of.” We do not hear the important because we do not listen. We do not see the important because we do not really look. Realizing this, we must use as many of the patient’s physical senses in teaching as we can and as often as we can to make a firm impression. We must re-emphasize, paraphrase, repeat, and review. We must build mental pictures through analogies and frequent varied examples and comparisons.

Teaching helps the patient, and it helps the practice. Patients want to understand and appreciate the features and benefits of the health services offered. Patients want to learn and be informed. Motivation to learn and appreciate must not be taken for granted; it must be constantly stimulated through repetition of benefits (personal value). Each patient must be shown the personal value for each consultation, examination, therapy, teaching, and policy. If they are not convinced of the value, they will only think in terms of time, price, effort, and immediate results.

External Communications

Patient education within the office is only one method of filling the communications gap. In the office, the patient is a captive audience. Communications outside the office for both assistant and doctor takes more assertive action. External communications of this nature means arranging for the practice to get noticed, remembered, and known throughout the community.

The practice also receives recognition when it bestows recognition. Local newspapers offer an abundance of announcements by which the office can recognize the achievements and advancements of others. Congratulatory letters are welcomed and remembered. The office that “doesn’t have the time” to get involved with the community is all too often the office that the community doesn’t get involved with to any great extent. Think and talk good about people, and they will think and talk good about you.

Remember that it is the extra and unusual that impress people the most. It’s usual to send greeting cards at Christmas; it’s unusual to send cards at Thanksgiving. It’s usual to have black-and-white letterheads; it’s unusual to have blue or brown letterheads with a matching typewriter ribbon. There is nothing unprofessional about being unusual if it is done in good taste.

Health practice begins with a desire to serve others. It is not a gimmick. Therefore, when you join community clubs and organizations, it should never be a gimmick to gain personal attention. You can expect only to receive in the same spirit in which you give. If you give sincerely and freely of your time to community affairs, the community will return in kind. Dedicated community service is a medium to further your professional image and that of the practice you serve.

Enthusiasm Is Contagious

The more successful the practice, the better setting for the CA to have opportunity for career development and advancement. Thus, besides loyalty and efficient job performance, the assistant has a strong personal motive to assist in practice development.

Enthusiasm is contagious if it is natural. Enthusiasm is not something that can be learned in the 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 performing an important job in an important field, you have a right to be enthusiastic about your occupation and the people with which you are associated.

Effective salesmen are enthusiastic salesmen because people like enthusiastic people, and of course, you are a salesman for your office, your doctor, and for the profession of chiropractic. By being affirmative, cheerful, and confident about your position and work, you help people like you more because you project interest through your enthusiastic attitude. Because enthusiasm is contagious, the best way for you to encourage people to have greater interest in you and confidence in your employer is to display such confidence.

At parties, club meetings, showers, and other social affairs, you will inevitably be asked about the job you hold. When you reply that you are employed in a chiropractic office, the next question will likely be, “How do you like it?” If you enjoy your work, you can win friends for the office by saying enthusiastically that you enjoy it. If you do not enjoy it, it’s a sure sign you are in the wrong occupation. If you respect and admire the doctor and what he does, say so from the heart. If you do not, you should certainly look for other employment. People who have no opportunity to know about chiropractic in general or your doctor-employer in particular can learn about chiropractic through you.

The enthusiastic assistant does not lock her job in a desk at night. When she leaves the office, she takes the excitement and challenge of chiropractic with her. She discusses it with her friends. She explains what it is, what it does, and the health services provided. It would be a rare person you meet that would not benefit from the services of a chiropractor at some period in life. Most people need chiropractic health care periodically. You do a distinct favor for your friends, your doctor, yourself, and your community when you help them to select a chiropractic physician whose professional skill, concern, and integrity are acknowledged.

Use of Conversational Terms

Avoid pretentious, archaic, and inaccurate terms. Use simple conversational terms for efficient communication. For example:

Word or Phrase                    Replace with

acknowledge receipt of            thank you for
advise                            explain, let know
are able to                       can
are being included                are included
are in a position to              can
as per                            as, according to
at all times                      always
at an early data                  soon, promptly
at hand                           here
at the present time               now
at the present writing            personally
come to hand                      reached us
deem                              think, believe
do it on (next) Monday            do it Monday
enclosed herewith                 enclosed
hand you                          send, enclose
have before us                    has reached us, we have received
hence                             therefore, thus
hereafter                         after this
heretofore                        until now
his own experience                his experience
in accordance with your request   as you requested
instruct                          inform
it helps in planning              it helps planning
meets with your approval          find satisfactory, you like
note                              see, understand
past experience                   experience
subsequently                      later
takes planning                    requires planning
up to this writing                until now
utilize                           use

Personalized Expressions

Whenever possible, use personalized expressions rather than impersonal phrases. For example:

Common Expressions More Personalized Expressions

Your letter              Your helpful letter

Your reply               Your prompt reply

Your answer              Your thoughtful answer

Your explanation         Your clear explanation

Your suggestion          Your constructive suggestion

Your question            Your interesting question

Your problem             Your personal situation

Your guess               Your insight

Untactfull vs Tactful Expressions

Tactful expressions add leverage to your persuasion. For example:

Untactful Expressions              Tactful Expressions

You failed to sign the check.      The check was not signed.

You omitted the ….               The … was omitted.

You forgot to enclose the ….     The … was not received.

You made an error.                 We need you help to correct a mistake.

You did not understand.            We did not make it clear that ….

You are confused.                  I understand your confusion.

Negative vs Positive Expressions

Negative expressions focus involuted attention. Positive expressions encourage constructive action.

Negative Expressions               Positive Expressions

Do not hesitate to inform us.      Please write.

Thank you for your trouble.        Thank you for your help.

You won’t be sorry when (if)…    You’ll be happy when (if) ….

To avoid further delay ….        To speed delivery ….

These data are insufficient.       Would you like further information?

IT’S NOT ALWAYS WHAT YOU SAY, BUT HOW YOU SAY IT

An assistant should never let a patient browbeat her (eg, for the sake of economy or expediency) to do anything that would not be ultimately in the patient’s best interests. Actions should be designed to enhance the doctor-patient relationship and support the doctor’s authority in case management.

Semantics and Case Management

During the course of treatment, never ask a patient, “How do you feel.” If the patient does feel better, fine; if he does not, you invite a complaint. It is better to greet returning patients with a positive question such as, “What improvement have you noticed so far?” This suggests to the patient that it takes time for the healing process but improvement is expected. However, if you can see obvious improvement, there is nothing wrong in mentioning it to the patient. In fact, it is positive reinforcement.

Patients rarely leave a practice because they have a complaint. Strong messages can often be stated softly, but the feelings behind them can be loud and clear to an attentive ear. They leave when people involved do not listen. Some innocuous phrases and their frequently hidden meanings are listed below.

Message                                Meaning

I need your advice on something.       I’m really confused.

No, I’m not upset!                     I don’t want to talk about it

                                       because you never listen to my

                                       vewpoint.  
I know, I know.                        Stop bugging me. You’ve said

                                       this all before, but I have my

                                       own reasons for doing it this

                                       way.
I was afraid this would happen         I told you so. I tried to warn

                                       you, but you wouldn’t listen.
Let’s think about it for awhile?       I’m not sold on it.                     
I agree, but ….                      You’re dead wrong, and I’ll show

                                       you where     
It doesn’t matter!                     My feelings don’t count, do

                                       they?        
That’s a ridiculous deadline.          What’s in it for me

                                       for the extra effort?        
Sorry, it’s office policy.             My opinion is fixed.                    
Some people think that ….            I think that ….                       
It was an accident.                    Will you forgive me?                     
He’s that way with everybody.          He’s that way with me

                                       too!               
You’ve got to be kidding.              I’ve about reached my

                                       limit.           
What I’m trying to say is….          Would you PLEASE listen?

Any patient complaint, no matter how seemingly casual or trivial, should be taken seriously. Evaluate every comment, and follow with appropriate comment or action. During acute illness, complaints may come from family members who are apprehensive about a loved one. Do your best to ease their fears or they may be passed on to the patient, but never infer a “promise” that could be mistaken as a guarantee.

You will occasionally be exposed to a sensitive human-relations situation in which a patient mentions that another doctor or a member of the immediate family disagrees with your doctor-employer’s opinion. When this happens, maintain professional poise, be courteous, and disagree friendly. Indicate that while you respect the other person’s opinion, your employer has a fine reputation for having excellent judgment in such matters. Build the doctor without tearing down another person.

Help the patient recognize that the doctor is not a magician. The patient must assume a share of responsibility in the healing process such as following the doctor’s advice and recommendations. The doctor’s role includes teaching the patient certain preventive practices, explaining methods to enhance the healing process, educating the patient in certain dietary habits and therapeutic exercises, or recommending acts such as more rest, staying home from work, and activity changes. A patient’s recovery depends a great deal on active participation in the health program. The chiropractic assistant serves the patient’s and the doctor’s best interests when she encourages the patient to become actively involved in the health plan.

Only a fraction of lost patients can be attributed to death, moving, unadjusted complaints, lower prices, or better services in the business world. The majority lose interest because of personnel indifference or disinterest.

A breakdown in human relations is the major cause of patient loss. There is no reason to think this is not also true in health practice. Patients who are responding well and those who are not will remain in the practice if they feel the doctor and assistant are competent and interested in them as individuals. They leave the practice when interest is not continually reinforced. This interest is maintained by having single-minded focus on the patient, his condition, and his problem.

Both doctor and assistant should leave all thoughts of family problems, organizational interests, and other personal concerns aside during office hours. Energies must be concentrated on and directed to the most important aspect of the practice—the patient. Every thought or act that is not patient oriented distracts from the quality of the practice. If thoughts of the staff are filled with patient concern, the practice will maintain positive momentum.

Periodic tests and examinations, comparative studies, and progress reports indicate to the patient the doctor’s thoroughness and concern. The assistant must be aware of the purpose of these procedures so she can reinforce their need and benefit whenever the opportunity arises.

Semantics and Patient Relations

Many expressions mean different things to different people. The effects of semantics on good human relations are difficult to overemphasize. Technical words between doctor and assistant often become matter-of-fact among the staff, but we should remember that chiropractic terminology is often “over the head” of the average patient. When patients are exposed to confusing terms and do not understand them, they can feel “put down,” uneducated, and alienated. When you see that “gazed, confused” look, respond with, “In other words, ….”