January 2006

The new patient attracting image

by Dr. Peter Fernandez

Part 13: Progress examinations ‑‑ when and why

First, let's review the purpose of an orthopedic exam. In this type of examination the doctor guides the patient's parts through their range of motion to determine if any of the motion causes pain. The position of the part when the pain is produced is a major determinant in the plan of care that the doctor will prescribe for those patients in pain. A patient with a high pain threshold, often will feel little pain until the doctor guides his or her part through its range of motion. Therefore, if a doctor is to prescribe the best plan of care for the patient, he or she must not solely rely on the patient's reported symptoms, but on the patient's objective findings (something the doctor can feel, see, smell, hear, etc.). An orthopedic examination will reveal these objective findings.

How does an orthopedic examination relate to a new patient attracting image? Simple. It's during the examination that the patient is impressed to the point he or she is "sold" on the doctor. And, when a patient is "sold" on his or her doctor, that individual will follow the doctor's care recommendations and refer.

If the doctor is a subluxation‑based DC, a progress examination would seem unnecessary. The doctor's plan of care should be left to take its course, right? Absolutely wrong! The purpose of a progress examination is exactly what the title implies, to re‑evaluate the patient's health problem and determine what progress, if any, has been made. If the patient is progressing as anticipated, great! In that case, the doctor encourages the patient to keep doing what he or she is doing, and to continue following his or her plan of care as it is working marvelously. However, if the patient is not progressing at an acceptable rate or is getting worse, the doctor must determine why and make the necessary care adjustments, or counsel the patient more on what he or she should or shouldn't be doing at home.

The effects of chiropractic care and whether or not changes should be made to it, can be measured quite accurately. A doctor's goal should be to get his or her patients as well as possible, as soon as possible, and then to maintain optimum health. The only way to accomplish this is to regularly evaluate patient progress and make changes in care as soon as they are indicated.

In addition, progress examinations rekindle patients' interest in their care. Patients are encouraged when they witness improvement in their health or when changes in care produce more favorable results. These are happy patients. These are referring patients. These are your lifetime patients.

Progress examination rules

***  Rule #1: A progress examination is usually conducted on a patient every 10 office visits. There is no magic to the number 10, it's simply a point at which the average chiropractic patient's progress can be accurately measured. The doctor may use a different re‑exam time interval depending on his or her preferences or individual case, i.e., every 12 visits, etc., but should never postpone re‑examining a patient any longer than the number of visits it would reasonably take to determine if the patient's health condition is responding as anticipated to the prescribed plan of care.

***  Rule #2: The doctor always compares his or her progress examination objective findings to the objective findings of the patient's initial exam, to determine whether and how much the patient has progressed. Is the patient the same, worse or better than expected? If the doctor is unhappy with the patient's progress, or the patient's condition has worsened, something is wrong and the doctor must determine what that is, i.e., the prescribed plan of care is not right, or the patient is ignoring the doctor's at‑home instructions and activity precautions.

Let's assume a patient starts care with nine objective findings. Ten visits later the doctor performs a progress examination and finds the same nine objective findings. Something's wrong, badly wrong! At this point, the doctor must determine if the diagnosis/analysis was accurate. If it was, the doctor must next re‑evaluate his or her care recommendations. It's obvious the doctor's initial plan of care isn't working as anticipated, and something must change.

Ten visits after changing the patient's plan of care, the doctor will perform another progress examination to determine if the patient has made satisfactory progress. If the patient then shows only five of the initial objective findings remaining, the doctor's new plan of care is working. In a case like this the doctor would stay with his or her new care program until the patient is clear of all objective findings.

However, if in another 10 visits after changing the patient's initial plan of care, the patient's progress examination still shows the original nine objective findings or more (the patient is worse), a referral to another chiropractor may be in order.

Let's look at yet another scenario. A patient starts care with eight objective findings. After 10 visits, the patient's progress examination reveals only four objective findings. The patient's health problem is not as bad as when he or she first came in, so it's time to reduce the frequency of care, right? WRONG! If a doctor's plan of care results in a 50% reduction of objective findings after just 10 visits, it's an absolutely superb care plan. Why change it? What works, works! An obviously effective plan of care should be continued without alteration (including frequency) until all objective findings have been chased out of the patient.

***  Rule #3: Progress examinations should be continued until all objective findings are eliminated. Lifetime care is now necessary to preserve the progress that has already been made, and to assure the patient a healthy lifestyle.

***  Rule #4: A common practice is to, "only re‑examine positive findings." But this is like practicing with blinders on, and is definitely not the common practice of a good and highly competent doctor.

When a doctor performs a progress examination, he or she must re‑examine the entire part, not just the parts that were positive on the first exam. Why? Because this is the only way the doctor can determine if the patient's health problem is progressive, and be able to measure any existing progression. By only re‑examining positive findings, the doctor is effectively ignoring any new and otherwise detectable, objective findings the patient may suffer and that are directly related to the initial objective findings. This is a major disservice to the patient.

***  Rule #5: Always perform a progress examination prior to reducing the frequency of care. Patients need to trust their doctor's judgment and this trust is jeopardized when a doctor changes his or her frequency of care. When a doctor does this without first conducting a progress examination, the patient thinks the doctor has simply changed his or her mind for no apparent reason. This creates serious doubt in the patient's mind as to the doctor's level of competency, and the patient will dismiss himself or herself from care ‑‑ exactly the opposite to what the doctor wants. However, changes made to the patient's plan of care after a progress examination has been conducted, is not perceived as a change of mind on the doctor's part, but as the doctor determining the next phase of care.

***  Rule #6: The doctor should always perform a progress examination when he or she feels the patient is ready to be dismissed from care or is going to dismiss himself or herself from care. This procedure will either justify the doctor's decision to release the patient, or reveal the patient is not yet ready ‑‑ has not yet reached MMI. Another reason to perform an end of treatment re‑examination, is to document the patient's condition at the time of release, which could save the doctor from bogus claims of patient abandonment, and could also save insurance companies from having to pay out on claims for injuries not received as a result of a covered incident.

Properly performed progress examinations result in better follow through of your care plans, bring faster relief for your patients, get your patients well quicker, and provide a solid basis for your maintenance care recommendations. In other words, progress examinations make you a much more believable and respected doctor ... which is vital to your new patient attracting image.

Coming up: Specific re‑reporting guidelines that motivate patients to follow and complete the care you prescribe.

(Dr. Peter G. Fernandez, is a 1961 Logan graduate. His practice with five staff chiropractors and 12 satellite offices, was one of the country's largest all‑referral, high income chiropractic clinics. As a practice consultant for the past 24 years, Dr. Fernandez has taught practice building techniques to nearly 15,000 DCs, and consulted in the opening of approximately 3,000 practices. Write to him at Fernandez Consulting, 10733 ‑ 57th Avenue North, Seminole, FL, 33772, call 800‑882‑4476, or e‑mail: DrPete@DrFernandez.com. Visit www.MBAchiropractic.com for free practice building newsletters.)