What do you do when you have treated a patient a number of times for their problem and there has been no noticeable change? How do you respond when they come reporting a particular problem, and after interviewing and examining them, you determine that what they believe to be the problem is not at all the source of their distress? I think we have all faced these types of things many times.
People come to acupuncture, as we all know, with high expectations. We are often the treatment of last resort. Our patients are often the "bottom of the barrel," "train wreck," or simply complex patients who have not yet been helped by anyone else. Some have been avoiding care they should have had. Some are avoiding changing diet or activity, getting surgery, taking necessary medication, or even just seeing the doctor because they don't have insurance. We have all seen these patients; they come to us hoping that acupuncture will be magic in the face of problems that, with proper care or behavior change, could have been helped before or avoided completely. Sometimes they are hoping we can keep them out of surgery or off meds when that is not safe or wise.
Talking with patients about the limitations of our treatment and the seriousness of their conditions is tricky. We do not want to insult the patient, but we must address the situation in some way to help them see that we are aware that our treatment may not meet their (sometimes unreasonable) expectations.
Speaking of cases where the condition does not respond, I have heard stories of practitioners who continue to treat patients, twice a week for many months, with no change in the condition. I wonder how this happens. Does the patient just implicitly trust the practitioner, even though no noticeable change is occurring? Does the patient have an unlimited amount of personal funds to spend on this adventure? Is the patient getting some secondary gain from the treatment relationship, even though the presenting symptoms are not improving? Does the practitioner have a way of keeping the patient hoping for more? If there is no improvement, has this been discussed and a new treatment agreement negotiated? Or does the practitioner keep promising that things will get better once the "deepest levels" of the illness are cleared by the treatment? I wish I could be a fly on the wall in the treatment rooms where this occurs.
Practicing in Iowa, I have had many opportunities to watch the ethical problem of letting patients continue care who are not benefiting because of the large preponderance of chiropractors in our state. I have been a patient myself, a long time ago, of a chiropractor who kept me coming back, week after week, when I was clearly aware that I had reached a plateau. I finally asked, "How do you know how well I am? And how will we know when I am done? And how do you decide what I need as far as frequency and length of treatment?" Of course, my insurance was covering all of it. I was quickly convinced that there was something amiss there.
Although I believe that things are better in general 20 years later, I know that there are still practitioners who keep patients coming (and paying) when what they should do is refer the patient. In a way, the pattern is one of collusion between the patient and doctor. The doctor gets in the habit of treating and not expecting big changes, and the patient gets in the pattern of having treatment that is not entirely successful but does not mind because it is very low cost to them as long as insurance is paying. Some practitioners do minimal assessment, so they have no good measure of how the patient is doing. And some patients, as we all know, are not good reporters.
Some practitioners may unconsciously make their personal financial interests the most important determinant of whether to keep or refer a patient. Instead of referring to a specialist, they keep adding new therapies to their practice so the patient never has to leave. Some practitioners just keep finding more things to treat for a given patient. After all, every patient we see has kidney deficiency, right? Of course, when insurance is paying, it doesn't cost the patient much, so why not go for helping the person as much as we can. (Please excuse the sarcasm)
So, I think it is extremely important for us to be aware, conscious and perhaps overly-ethical about these issues. We need to err on the side of being more ethical than the average bear on this stuff. This helps the public learn that we are professionals with high ethical standards who deserve to be trusted and can bill insurance, clearly and honestly, for our services. We may need to be more ethical on these issues than any other profession that has come before us. We need to be able to be totally frank with people about when we think we cannot help them and what we think they need to do instead of coming to us, including referring out.
Referring patients will also benefit our personal incomes. Many people have come to me who said, "I knew you were the right one to call because my friend said you were so honest about the fact that you could probably not help her any further." Ironic, perhaps.
I have a patient who has come every week for more than 12 years. She comes with the diagnoses of fibromyalgia, migraine, asthma, allergies, irritable bowel, chemical sensitivity, and so on. Early in our work together, I thought that she was making far fewer gains than I wanted to see and told her that I would refer her to someone else. She begged me not to do that. She had seen just about everyone else by then. I told her that when someone is not responding to treatment, I cannot continue to treat them and must refer them. She said something very interesting. She told me that without acupuncture, she would have so much pain that she would have killed herself.
As I learned more about acupuncture through practice and study, we worked together. On a regular basis, I would ask how things were going for her regarding the treatment, and she would always repeat that sentiment about not killing herself. She said that without acupuncture she would have no life at all. With acupuncture, she could count on a few pain-free days per week, and could actually accomplish a few things. I accepted her view and kept her on as a patient.
Recently, after I have learned some more powerful approaches to acupuncture, she has begun getting much better. No migraines, no asthma, no allergies, much less pain. Recently during the icy winter, she was often outside shoveling and in the spring was digging a trench in her yard to manage runoff. She has gotten much better, and I have continued, at times, to threaten to send her away. But she says that if she misses a week of acupuncture, she just does not do so well. So I accept this and am assured that I would not be unethical keeping her in treatment, despite the slow progress. We stay in close contact regarding this issue, and keep our contract clear at all times so there is no misunderstanding. This is the type of case that would be tempting for many people, to take advantage of the dependency of this patient, and perhaps not be alert to the lack of change, or the improvement, and just count on the patient as one of the "regulars" whose payment is a given.
My point in all of this is to say that we need to be careful to let people know when we think we may not be helping them. We must then refer them to another practitioner whom we believe to be well-suited to help this patient. If the patient does not accept a referral, we must have a very clear agreement about the focus of ongoing treatment and keep that contract clear at all times. By doing these things, we will not find ourselves in a position to be accused of taking people's money without delivering on our promises. In other words, we will not be accused of having our own financial interests as the driving force behind our treatment plans.
The fact that most of our patients pay cash makes this even clearer. For the profession at large, as well as our personal reputations, we must be honest about what we expect from the treatment, forthcoming when we don't know what to expect and willing to admit when we believe people are not benefiting. They will appreciate our honesty, which will improve people's impressions of acupuncture and will help to grow our practices. Not to mention the ethical problems with making promises we can't fulfill, and taking people's money when they have gotten no benefit at all.
My hope is that by being honest about our areas of weakness and clear with our patients about our limitations, we can empower our patients, improve the reputation of our profession and improve people's impression of us and, ultimately, our financial status.
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