Got Trust?

Thank you for the many responses from my last article. All I can say is that e-mail certainly works!

As health care practitioners, we are bound by two tenets: "First, do no harm"; second, "do some good." Prospective patients come to us usually because they are in pain and need relief. You need to "do some good." They certainly didn't come to your office to get worse, so you must "do no harm." Sometimes, it's difficult to balance both.

I believe that just about anything with a potential to help has a potential to harm. This extends to acupuncture as much as any other health profession. It's easy to believe that Oriental medicine is foolproof, but it simply isn't true. There are plenty of herbs with harmful side effects and drug-herb interactions to worry about. There are also certain risks with needles, electrical stimulation, exercises, etc. Even without these factors, nothing works on everybody all the time. It is very dangerous to think otherwise. Practitioners must weigh the potential risks of a treatment or exam procedure (do no harm) against the benefits (do some good).

Deciding on these procedures isn't just about you, either. Think of practitioners who refer patients to you. If patients get better under your care, they will give a glowing report to the referring doctor. You will look good, and so will he or she for making the referral. If a patient gets worse under your care, they will give a different (and usually negative) report to the referring doctor. The referring doctor will likely not be happy either. Unless you have a good working relationship with them, it could mean the end of your referrals from that practitioner.

Instead of the "don't worry, I'll save you" mentality that sometimes gets conveyed to patients, I tend to adapt a more cautious, yet optimistic tone. In my initial patient visit, I will usually tell them that just about every form of treatment I know of is a "miracle" for some patients; does nothing for others; and sometimes people get worse. After over 20 years in practice, I still can't tell exactly what treatment or regimen of treatments will work on an individual patient. It's an educated guess based on my experience, training, and some intuition thrown in. I don't have a crystal ball. I will tell patients that over the next few visits, we need to find their "miracle." At the end of the first couple of weeks, we'll either know I can't help them, or we'll know what works for them. That kind of honest discussion usually engenders a lot of trust with the patient. That trust is at least as important as any treatment I provide.

There are some conditions I have learned never to treat right off the bat. With those cases, I will refer the patient to someone I know and trust in the appropriate specialty. Telling a patient to look a specialist up in a phone book simply won't do. For example, if I see a patient with a fresh trauma and signs/symptoms related to spinal cord compression, it's not something I am personally comfortable treating without a consult referral from a trusted orthopedic surgeon or neurologist or both (first, do no harm). When the patient returns from one of those practitioners, I feel much more comfortable treating them.

In legal circles, this is known as "shared liability." In my world, this is known as stress relief. Patients are usually much happier to be referred out to someone and will trust you all the more. I have gotten far more letters of appreciation, bouquets of flowers, and other "thank you" gifts for doing this than any type of "miracle" treatment I provided. It is crucial to develop a good referral network if you haven't done so.

When another practitioner refers a patient to you, that patient tends to have a lot more trust in you. You must be someone special if their doctor (who they trust) sent them to you. This type of referred patient comes with some built-in trust and faith in you before you've ever met. Sometimes it's a little too trusting. I am always a little wary when a patient informs me that I am going to "cure" them, or that they "know" that I am "the one." That's too much trust. I think patients should retain a little skepticism. They should question me about methods, what they are supposed to achieve, when can they expect results, etc. As someone once said, blind faith (trust) can kill you.

It's always good form to call the referring doctor and thank them for the referral. You should also ask f there are any special instructions or precautions you should know about that patient. Also, once you have seen the patient, you should send a brief letter or report to that referring doctor about what you've found, what you intend to do, etc.

If the patient gets worse, do not hesitate to send them back to the doctor, or at least call that doctor and inform them. If you were referred by an orthopedic surgeon and you feel the patient should see a neurologist, rather than just sending them to the neurologist, it is much better form to call the surgeon, ask if they think the patient should be evaluated, and if so, what neurologist they would prefer. You can then call that neurologist. Bingo: you've eveloped another referral source for yourself. In the event your referring doctor doesn't know one, you can refer to one of your choosing.

If you refer an existing patient to a specialist for a consult, that specialist should do the same for you. They should call you and inform you that the patient should see a different specialist and ask if you have a preference. This also builds interprofessional trust, something many health professions could certainly use these days.

By practicing this way, you will help your patients much more than having "kept" them to yourself. You will multiply your practice referrals. You will practice in a much safer manner. You will probably save someone's life one day (e.g., discovering a tumor early). You will develop a wonderful reputation in the health care community, not as a "renegade" acupuncturist, but as someone who can be trusted. There are many other good places this type of networking will take you.

If after reading this, you still aren't sure how to set up a referral system, think about taking a program or seminar on the subject. These programs are designed to help you function far more as a primary care practitioner. Trust me: they work.