Managing difficult chiropractic situations

Chiropractors regularly deal with challenging situations and are continually required to make difficult decisions.  However, these decisions don’t always relate solely to the clinical care they’re providing their patients.  Unfortunately, sometimes chiropractors will face other difficult situations with their patients and knowing how to manage these isn’t always easy or obvious.

The information below highlights three challenging scenarios, which are not uncommon in chiropractic, with tips on how they could be managed.

Patient requesting specific treatment

Some patients will attend their chiropractic appointment with what they believe is an understanding of their condition and how they should be treated.  These patients will often request, maybe even demand, a particular type of treatment.  This information may be based on how they’ve been treated by a chiropractor in the past.  Sometimes it will be based on information non-clinically trained people, such as friends, have shared with them or even information they’ve read online.

Chiropractors must be sure all patients are assessed thoroughly regardless of what the patient tells them about their condition; the chiropractor as the health professional needs to be sure.  Following the assessment, the chiropractor may determine that the treatment being requested isn’t appropriate for that patient based on their current clinical situation. 

When the treatment the patient has requested isn’t ideal for them, they may not be happy with the decision to not provide this.  This requires the chiropractor to explain to the patient what treatment is recommended and why.  Chiropractors must be sure they don’t allow themselves to be coerced into providing treatment against their better judgement and they need to be sure all treatment they provide is clinically justified.  If there is a poor outcome following treatment and the choice of treatment is questioned, stating that the patient demanded that treatment isn’t a justification for it being provided.

In many cases, the patient will accept the chiropractor’s treatment recommendation.  However, chiropractors need to be prepared for the possibility that some patients won’t agree with this recommendation and may leave the appointment disappointed.  Unfortunately, it’s not possible to please all patients. 

If the situation above occurs, it’s vital that the patient’s request is noted in the clinical record so there is a full history not just of what treatment was provided but of all conversations regarding the treatment.

Patients seeing multiple practitioners

Some patients will choose to visit multiple practitioners for the one condition.  A common reason for this that they aren’t satisfied with the treatment outcome from one practitioner, so they try others hoping for a different result.  They may choose to see different chiropractors, or they might see different types of practitioners such as osteopaths and physiotherapists as well as a chiropractor.

In most cases, a patient seeking a different opinion shouldn’t be cause for concern.  However sometimes a patient who has seen numerous practitioners and has been unhappy with them all may be a patient who’s difficult to please and chiropractors should be mindful of how they manage this situation.

In cases where a patient presents criticising the treatment provided by another practitioner, it’s important that chiropractor doesn’t also criticise this treatment.  The chiropractor doesn’t have the full story of how the patient presented to the other practitioners, what treatment was provided and why.  Criticising the work of other practitioners is not only unprofessional, it can also encourage, even if unintended, the patient to make a formal complaint about that practitioner.

Quite often patients are unhappy with their treatment outcome due to them having unrealistic expectations.  Assisting a patient to form realistic expectations about treatment requires effective communication before treatment starts.  Therefore, be sure that with all patients the likely and realistic treatment outcomes are discussed with them prior to any treatment being performed.  And this conversation needs to be had using language they’ll understand so avoid clinical jargon.

If a chiropractor has a very uneasy feeling about a patient due to it appearing difficult to meet their needs, the chiropractor can decline to provide treatment.  However, the chiropractor needs to acknowledge that not providing treatment could upset the patient.  Therefore, this discussion needs to be planned and worded in a way unlikely to cause offence.  Exactly what is said will vary depending on the situation, however it would be reasonable to let the patient know that due to the patient not getting benefit from previous treatment similar to what would be provided, the chiropractor may not be the most appropriate person to provide further treatment.  The patient could be advised to see another health professional such as a medical practitioner.

Blurred boundaries

The relationship between a patient and chiropractor is a professional relationship.  However, at times the behaviour of patients and chiropractors can blur the boundaries of this relationship and it can start to seem more of a personal relationship which isn’t appropriate.

Chiropractors need to remember that their patients are just that, patients.  They aren’t friends and shouldn’t become friends.  There are a couple of simple rules to follow to avoid this change of relationship.

Chiropractors should avoid socialising with patients.  Sometimes a chiropractor will treat a patient and their family for many years which leads to them getting to know each other quite well.  This can lead to chiropractors being invited to family birthdays and other events.  While it may seem impolite to decline these invitations, accepting them can complicate the professional relationship. 

With the continually increasing use of social media, there can be a temptation to connect on social media with a large number of people.  If a chiropractor has a professional social media account, only used for professional communications, it’s okay to connect with patients through this account.  However, chiropractors shouldn’t connect with patients on a personal social media account.

Chatting to patients during consultations is a great way to seem more personable and make patients feel relaxed.  However, if there is too much personal chatting the chiropractor is possibly not spending enough time discussing the treatment being provided.  Also, there have been occasions when personal conversations have been misinterpreted by the patient and they’ve felt uncomfortable with the chiropractor discussing information not related to treatment.

Unfortunately, keeping clear boundaries can be a little challenging for those chiropractors practicing and living in small towns or communities where many people know each other.  In these situations, the chiropractor needs to ensure that if they are treating someone they know, they maintain their professional standards during consultations and not treat these patients differently to others. 

Managing difficult chiropractic situations

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    Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791.  This article contains information of a general nature only, and is not intended to constitute the provision of legal advice. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them    .

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    Guild Insurance spends a significant amount of time analysing the chiropractic claims reported to us. This analysis helps us to understand what patients complain about, factors which might make some patients more likely to complain and what actions from practitioners make it challenging to defend these complaints. Following this analysis, Guild, in conjunction with the Australian Chiropractors Association, creates risk messages and learnings to share with and educate chiropractors, with the aim of reducing complaints. The following details Guild’s key learnings for the chiropractic profession based on this claims analysis.

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    All chiropractors would be aware of their requirement to keep detailed clinical records. Yet, unfortunately, Guild’s claims experience tells us that too many chiropractors aren’t keeping these records to the detailed level required. 

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    All chiropractors should make themselves familiar with the record keeping resources available on the Ahpra website which can be found at www.ahpra.gov.au/resources/managing-health-records.

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    It’s not enough to have a patient sign an informed consent form. This form, if used, is there to support the conversation, it can’t replace it.

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    Breakdowns in communication feature in almost all complaints from patients. Sometimes the patient will complain about how they were communicated with, while other times communication may not be mentioned in the complaint yet when the matter is investigated, it’s found to have been a factor. Therefore, the importance of appropriate and professional communication can’t be overlooked.

    When communicating with patients, it’s important to use language they’ll likely understand, so avoid overly clinical terms and acronyms. And don’t rely on just verbal communication, tools such as diagrams and models can assist greatly.

    When communicating with patients, be sure to keep the conversation professional and appropriate. While it’s important to form a good working relationship with your patients, there also needs to be a professional boundary. Chiropractors must ensure that topics discussed, and language used, don’t blur this boundary.

    Professional conduct

    Guild Insurance has seen an increasing trend in complaints from patients that focus less on the clinical outcome and more on how the patient viewed the professional behaviour of the practitioner. It’s becoming very clear that patients have high expectations regarding how health professionals conduct themselves and are willing to complain about this conduct.

    A new shared Code of Conduct (shared between 12 health professions) was released in 2022. Chiropractors need to be sure they’re familiar with this Code of Conduct as it details what Ahpra, and the Chiropractic Board of Australia expect regarding professional behaviour. This can be found at www.ahpra.gov.au/resources/code-of-conduct/shared-code-of-conduct.

    As mentioned earlier, maintaining professional boundaries is incredibly important. Chiropractors need to be sure their behaviour, as well as communication, maintains these boundaries. They shouldn’t become too familiar or casual with their patients or take advantage of the power imbalance between a health professional and patient.

    Clinical decision making

    Chiropractors need to be sure their decisions regarding when and how to treat are always in the best interests of their patients.

    No health professional can be the answer to every patient’s needs. It’s therefore vital to be sure you’re only treating when it’s appropriate to do so. When chiropractors see patients who should be treated by a different health professional, they need to refer that patient to someone more suitable, explaining the reasons for this to the patient. Chiropractors should also be sure they don’t allow themselves to be convinced by the patient to treat when it’s not appropriate.

    Chiropractors need to ensure that any treatment or clinical advice they provide is within their scope of practice and something they’ve been suitably trained for. While all chiropractors will develop their skills over time, this development needs to happen while keeping in line with the chiropractic scope of practice.

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