The person seeking help from a chiropractor has undergone an internal process of evaluation, introspective question and answer, and perhaps, a bit of investigation with others, before ever contacting an office for help. I contend that by exploring what is in the patient’s mind during this discerning process, initially, and then, each day you encounter the patient, insight into how to do a better job of meeting the patient’s expectations, and attempting to actually exceed them is obtained.

Pain and fear share a great deal. Fight or flight: an elevated heart rate and or increased respiratory rate, anxiety, desperation, and at times, anger. A patient seeking your help is driven to you by a combination of physiological and psychological responses or reactions. The conventions of society, though less rigid than in generations past, still demand people maintain a dignified countenance, even in the face of personal physical challenges. This internal battle between our primal human tendencies and expected social bearing often increase a persons stress level to a very high degree. This is the person that presents to you for help; a frightened, anxious, irritable but often, artificially constrained individual.

“It’s a great day at Back Pain Chiropractic, my name is Wendy, I can help!”

The underlying conversation playing itself out in the patient’s head is likely to be something similar to:

“It may be great where you are, but right now my life really stinks because of this [fill in the blank] pain!”

However, though many think similar thoughts, it is a rare patient who will actually state something out loud or be noticeably irritated. That said, doctors and team members must remember patients are listening and observing carefully what is said to them directly, or even in their general vicinity. Patients are also sensitive to the way your protocols and procedures are implemented. For example, the length of a telephone call can be unbearable to someone in pain, and the words used can also be a challenge to their patience. Even when a call goes without a hitch, it may seem to go on forever to the person barely able to stand, or sit comfortably, to make the call in the first place. Being considerate is a must for all involved with patient care. And beyond that, listening to the patient’s voice inflection, speech rate and the way they phrase their sentences and responses is critical to defining their expectations and connecting with them. An initial phone call must address the patient’s state of mind, and acknowledge, then allay any fear or anxiety the patient has in calling the office. The office team must be fully trained for this interaction to be fruitful.

In many cases, new patients calling an office for the first time are “irritated away” by the insensitivity of a staff member, or a lack of organization, resulting in a poor first impression. Regular evaluation of the office team’s abilities, and the office protocols extant, is critical to insure an “open door” for new people to enter the practice.

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What is the patient’s expectation?

“Who is this doctor I found in the phone book?”
“Nice website, but what is all this technical stuff anyway?” “Can I really trust this doctor?”
“This is scary, I wonder if I am doing the right thing?”
“How the heck much will this cost me?”
“I wonder if my insurance will cover this?”

At the same time, the new person may be thinking,

“Will he ‘crack my back?”
“Do I have a disc problem like Sally”
“Will this doctor hurt me?”
“What about strokes?”

These and a myriad of other thoughts may be, in fact probably are, in the patient’s mind, and all these thoughts have an impact upon the psyche of the patient. Doctors and team members must anticipate these questions and concerns in order to begin to create the all- important relationship upon which true patient retention is built. I recommend the team members refer all questions of a technical nature, or those that relate to the patient-doctor relationship directly to the doctor. Each doctor must determine the parameters for how these interactions are to be addressed, and then, train his staff to implement what is desired to achieve optimal results.

The manner doctors use to approach patients to begin the process of welcoming them into their offices and care is critical. Retention is based upon the relationship the doctor creates with the patient in need of their care. Development of patient retention begins from the first contact with the office and team. The relationship the patient develops with the team, the doctor and the facility, is comprised of feelings, intellectual evaluation, and acceptance, as well as the belief that the doctor has the potential solution to their immediate problem. All these feelings and thoughts create a level of expectation. Each patient’s level of expectation is unique to them and must be addressed accordingly.

The mistake many doctors make is to assume that because the patient is vulnerable and in immediate need of assistance, that they can create commitment with the patient as a result of the patient’s desperation. The doctor is taking advantage of the patient in this scenario. What then, does this all-too-common practice do, to the relationship between the doctor and the patient? I contend that, the desperate patient, who agrees to the cleverly presented demands of the doctor, for cost and duration of care, feels taken advantage of, and therefore, upon realizing a relief of pain (their true agenda), they take back their personal power and quit care: never to return. Abuse of power is a serious mistake in the doctor-patient relationship; it destroys trust. This position of advantage assumed by the doctor creates a circumstance that ruins the potential of the patient to form a new health paradigm based in chiropractic care.

The doctor, who truly connects with patients, is naturally empathetic, confident, but never cocky, and willing to personally engage the patient. It is this doctor who builds honest, long term, doctor-patient relationships. This doctor creates the opportunity to teach patients a new perspective on their problem and their health. The doctor’s communication skills are very important, however, how the doctor communicates and the honest impressions his communications convey are equally important to the doctor-patient relationship.

When a doctor has created a relationship based upon trust, the patient has a greater potential to succeed with care. When the inevitable challenges inherent in patient care present themselves, the patient trusts that the doctor, always putting the patients needs and feelings first, will advise them honestly. When legitimate choices are provided to the patient they invariably choose to work with the doctor for their benefit. The challenges that naturally occur as obstacles to patients continuing care are minimized when the doctor-patient relationship is solid.

What are the primary qualities that impact trust formation in the doctor-patient relationship? The patient’s first impression is critical. (See “Creating a Great First Impression” AJCC July 2005) Empathy, and a “patient centered approach.” (Wherein you obtain the information you need to fully assess the patient’s problem, while all the while involving the patient in the process.) Asking questions to define the scope and extent of the patient’s pain and the effect this pain or lack of function has on their activities of daily living (ADL). Planning your initial meeting, explaining what the initial visit will entail, your line of questioning, your physical touch, and explaining what you are doing and why, during the exam, it is important to build the patient’s trust in you. (See “The Start of Something Big, The Initial Patient History and Exam” AJCC October 2005)

The doctor who enters the consultation office to present the results of the initial history, exam, radiographic and PosturePrint studies to the patient, and who has developed a trusting relationship with the patient is given the benefit of the doubt when it comes to a decision to take up care or not. If the patient’s initial expectations have been met or exceeded, more often than not, the patient chooses care. Therefore, the patient’s opportunity for a brighter future with chiropractic care is realized.

Retaining each patient requires ongoing investment, initiated by the doctor, in the doctor-patient relationship. Regularly questioning the patient about what they think about your care, and how it is related to their life and function, provides you with the foundation to structure the education of each patient to their unique needs and level of understanding.

Just as it is critical to determine patient expectation when encountering patients for the first time, determination of each patient’s expectation on a regular basis is the most critical component of retaining patients. If you do not know what they are thinking, you cannot connect with them, and address their needs. Patient expectation is dynamic. It changes from day to day and week to week. A given patient, with perhaps 100 office visits over a period of many months or years, regardless the doctor’s relationship with them, up to that point, can quit care. Normally, when this occurs, it is because they feel the doctor stopped listening to them, or stopped meeting their (often changing) needs. Unfortunately for them, this means the doctor did not invest enough in the doctor-patient relationship to respond to them from a patient-centered perspective.

Once a solid trust based doctor-patient relationship is established, it must be cultivated during each and every doctor-patient interaction. Healthy relationships require constant attention to develop, and this particular relationship is no exception. The successful doctor is constantly vigilant and responsive to the patient’s needs, wants and expectations. Only then is a successful, productive, relationship realized, and dynamic patient expectation exceeded. The end result is that a patient is far more likely to benefit from the care they are provided. Over time the patient’s unique, individual understanding of the chiropractic paradigm will develop, creating the opportunity for improved structure and function in their life.

Assessing Patient Expectation and Building Retention
©2007 Dr. Scott J. Heun, Heun Consulting, LLC
All Rights Reserved
Originally Published in the American Journal of Clinical Chiropractic (AJCC)

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