'Country Doctor Ernest Ceriani Making House Call on Foot in Small Town.' Photo by W. Eugene Smith / Life Magazine Archives.

Up until the 1950s or so, many (if not most) medical doctors made house calls in addition to seeing patients in their offices. That was before they felt they needed $2 million in equipment before they could write a prescription for antibiotics. When medical went high-tech, the little black bag wasn’t sufficient, so house calls went out of fashion. According to a report in the Clinics of Geriatric Medicine, house calls accounted for 40% of physician encounters in 1930, 10% by 1950, and less than 1% in 1980.

The really interesting thing is, in recent years that figure’s been creeping back up and now hovers around 5%. Apparently, many MDs are seeing the wisdom of seeing their patients at home. Some even do it full time in order to rid themselves of their high-rent offices, expensive equipment, and costly staff. Others offer house calls in addition to office hours in order to provide services for elderly, bedridden or housebound patients, or even busy parents who can’t get to the doctor’s office.

Chiropractors appear to be even more willing to try this creative approach to patient care. One DC used his blog to explain to patients that that he was going to start making house calls. He totaled the time it takes for a patient to have a regular in-office appointment and, with the preparation, driving, and waiting, it came to about an hour just to see the doctor for 5-10 minutes. “There are tools that I will not be able to take with me,” he explained to patients, “but as a chiropractor and a massage therapist all I really need is my hands. I have my portable table …

so, if you need a chiropractor or massage therapist, but don’t like the hassle of driving to an office and waiting to be seen, give me a call. Or if you know someone who is housebound due to pain. I will also be working with hospitals to treat people in urgent care centers and emergency rooms. I hope to be able to bring chiropractic to those who want it more conveniently or who can’t get to me.

Others are trying a variation on house calls and setting up mobile offices, complete with tables, selected equipment, and other supplies. In New Jersey, for instance, Demetrios Kydonieus, DC, drives around the area in his “Wellness Wagon.” Daren Bethia, DC, offers services “to make receiving chiropractic care convenient to the sick and shut in, the busy small business owner, the stay at home mom who is busy with the kids, those with limited transportation or anybody who needs immediate treatment, but can’t make it to our office.” He offers both chiropractic and personal training sessions to people in and around Charlotte, NC.

Obviously, mobile offices and making house calls isn’t for everyone and it’s too early to tell if they’re successful alternatives to traditional offices. Still, these are definitely interesting ideas that we’ll be seeing more of in the future. I invite anybody who’s tried either of them to let me know of their experiences.

The next most important reason for the relatively low malpractice lawsuit rate is that people tend to have a more personal rapport with their non-medical health care professionals. These are the people who actually spend time talking with them, getting to know their health issues, and show a genuine interest in them and their families.

That rapport alone can help prevent problems like lawsuits and board complaints. Lawyers have long known that if patients like you, they’re less likely to sue you even if you mess up.

“Plaintiffs’ lawyers report that 70% of malpractice claims are brought because of physician-patient communication problems or as a result of the physician’s attitude,” said Paul S. Sanders, MD, and Debra L. McBride, RN, JD in an article for Minnesota Medicine.

Researchers publishing in the Archives of Internal Medicine reviewed 45 malpractice cases and found that, in 71% of them, plaintiffs had a bad relationship with their provider. More than a third (31.5%) said they felt “deserted” by their doctors, and nearly that many (29%) said they had trouble contacting the doctor directly.

The image of the friendly family wellness provider (the kindly neighborhood chiropractor, the sage old acupuncturist, the sweet and caring nutritional counselor) is fading. Today’s high-tech environment, competitive health care arena, and emphasis on keeping our “professional distance” have given our offices a harder edge, a less personal touch.

The result? More stress for you and your patients, more lawsuits and complaints – and less effective care.

The solution? Hone your personal skills (verbal AND nonverbal) just as rigorously as you update your clinical knowledge.

Here are some specific tips for improving your “tableside” manner:

• Give patients/clients your full, undivided attention.
• Be aware of your nonverbal communication.
• Apologize if you’re late for an appointment, or if there was any other problem associated with the visit.
• Train your office staff to pay attention to patients and show them respect.
• Learn to listen to patient/client complaints without reacting with anger or impatience.

Watch your non-verbal communication as well.

• Maintain good eye contact. Don’t be constantly looking elsewhere or reading from your chart or notes.
• Watch your facial expressions. Match your “face” to your feelings and don’t be afraid to smile when appropriate!
• Be alert to body language. When talking with a patient or client, don’t be checking your watch, tapping your fingers on the counter, or shifting your feet impatiently.

If people skills aren’t your strength, take a course such as one of the famed Dale Carnegie training programs (http://www.dalecarnegie.com/search_courses/select_subject.jsp?courseSubject=CIS) or one of the offerings from the American Management Association (http://www.amanet.org/training/seminars/communication-skills-training.aspx)

Many courses are available online. Just a few hours spent leaning the basics of interpersonal relations can work wonders for your practice!

And that’s not just my opinion. Look at this April 26 email message from attorney Keith Pendleton, JD.

“Last week, at the request of several ProviderLAW members in Texas, I took a look at a case that some of you may have heard about, but doesn’t seem like it has hit the national press yet. I have to tell you, as a chiropractic patient myself, what I discovered was something of a shock.”

“The Texas Medical Association – a founding member of an AMA-led nationwide consortium called the Scope of Practice Partnership (SOPP) – sued the Texas Board of Medical Examiners to remove the ability of chiropractors to diagnose. The TMA isn’t just suing the TBCE on any old grounds either. It is challenging the ability of chiropractors to diagnose based on State constitutional grounds.”

I don’t know about you, but when a lawyer says he’s “shocked” by something in the legal realm, that gets my attention. Here’s a brief overview/timeline of what’s going on:

1. In January 2006, the American Medical Association (AMA) announced an industry consortium known as the “Scope of Practice Partnership” (SOPP). The consortium was originally formed by the AMA, along with six national medical specialty societies and six state medical associations, including the Texas Medical Association (TMA). The stated purpose of the group, among other directives, was to “concentrate the resources of organized medicine to oppose scope of practice expansions by allied health professionals that threaten the health and safety of the public.”
2. In May 2006, the Texas Board of Chiropractic Examiners (TBCE) adopted rule 75.17 regarding the scope of practice for licensed doctors of chiropractic in Texas. The rule, formed in response to a legislative mandate made in the state’s Chiropractic Act, governed two particular procedures being performed by chiropractors in the State of Texas – Needle EMG and Manipulation Under Anesthesia (MUA).
3. In September 2006, TMA filed suit against the Texas Board of Chiropractic Examiners (TBCE). In its lawsuit, TMA challenged the chiropractic board’s rules for Needle EMG and MUA, saying that the rules violated the Texas constitution because they represented an infringement of the authority of the Texas Board of Medical Examiners. Further, the Medical Association challenged the right of chiropractic doctors to “diagnose,” arguing that only medical doctors have the right to diagnose patients.
4. In November 2009, a Texas trial court’s “summary judgment” ruled that TBCE’s rules regarding EMG and MUA are invalid. The Texas Chiropractic Association is appealing the ruling.
5. On August 16, 2010, the court is scheduled to hear arguments and testimony on the board’s rules regarding “diagnosis” with respect to Texas chiropractors’ scope of practice.

Clearly, this case is of monumental importance to Texas DCs. So, assuming you don’t practice in Texas, why is this a big deal? Let’s review: this lawsuit doesn’t just seek to prevent the expansion of the scope of practice of chiropractic in Texas. It’s an attempt to restrict what chiropractors have been doing in Texas for decades. And the battle is taking place on constitutional grounds in one of the nation’s largest states. Make no mistake: if successful, this lawsuit could have major ramifications for SOPP and DCs operating nationwide, not to mention their patients.

But don’t take my word for it. Let’s hear again from attorney Keith Pendleton.

“You may have the right in your State (currently) to diagnose….Then consider a few facts… Consider the fact that Texas chiropractors have been reimbursed for years by insurance to diagnose (e.g., state worker’s comp). Consider the fact that statutes like these are being challenged as unconstitutional. Consider the fact that they are being challenged by one of the founding members of a national consortium that is systematically challenging scope of practice nationwide and even publishes a chart of its current actions.”

Now, I’m not suggesting that anyone panic. This legal wrangling may take years to decide. But you need to be aware that the wheels are in motion, and that this is part of a bigger movement to concentrate power in the hands of those “real doctors” who already — along with the drug companies — have the lion’s share of power and influence over our health care system today. Think about it.

A patient arrives in your office and you adjust her spine and correct her subluxations.

By the time she walks out the door, her spine is on the way to being subluxated again because of her unbalanced gait. The fact is, regardless of your capabilities, you can’t effectively stabilize a patient’s spine and achieve long‑term results unless you discover and correct the cause of the subluxations.

But, the list of possible physical and emotional stress triggers which contribute to subluxations is so lengthy, discovering the cause is a challenge. The subluxations may have begun at birth, during childhood, or been caused by trauma from a fall or an accident. They may result from years of poor posture or unhealthy habits. Even if you successfully determine the causes, you may not be able to rectify the subluxations. But subluxations can also be caused, at least in part, by an unbalanced gait, and you CAN do something about that.

According to Mark Charrette, DC, a recognized expert in spinal and extremity adjusting, “There is a fine interplay between the movements of the lower extremities and the balancing of the spine. Normal gait causes repetitive motions to occur from the feet up to the head. Alignment and function of the pelvis, spine, shoulders, and head are strongly influenced by pedal balance or imbalance… Because a smooth and symmetrical gait is tied so closely to proper vertebral function, biomechanical problems in one or both feet can interfere with postural alignment patterns.”

In 1994, Terry Yocum, DC, reported in Practical Research Studies, that at least 75% of the population has some degree of leg length inequality, which can lead to excessive foot pronation,  leading to gait imbalance and finally, leading to subluxations. If you correct subluxations but do not correct its cause, are you truly helping the patient, or are you merely trapping them inside the revolving door of adjustments and re‑subluxation?

It’s not an easy decision to direct attention away from the spine to the feet. As chiropractors, our primary concern is to detect and correct vertebral subluxations. Therefore, we concentrate our efforts on the spine. But to really provide complete subluxation corrective care, we need to examine the feet and determine the need for orthotics to correct the gait problems that can translate into subluxations.

Many DCs shy away from working with postural problems or orthotics. They may feel such care is not strictly in the realm of chiropractic, or they may feel offering orthotics is a time‑consuming and difficult service.  Realistically, anything that prevents, corrects or addresses any component of the subluxation complex is rightfully within the sphere of chiropractic and in complete accordance with chiropractic principles. Just as a dental office should provide cleanings and dental care education as well as fill cavities, the chiropractic office should provide services that aid the prevention of subluxations, stabilize the spine and reinforce the power of the adjustment.

Chiropractors need to determine the necessity of orthotic support, specifically among patients who are less successful at holding their adjustments. Chiropractors also need to assist patients obtain high‑quality orthotics to help correct postural problems.

Fortunately, as a doctor of chiropractic, you have an excellent tool to determine quickly and easily, without expensive or complicated adjuncts to your practice. This isn’t a medical device but a truly chiropractic one, developed by one of the most respected leaders of the profession, Monte Greenawalt.

“Fifty years ago, as a chiropractor I had an idea,” he explains. “I wanted to create whole body support for my patients by effectively positioning their feet ‑‑ the foundation for the body ‑‑ with high quality, custom‑made flexible orthotics.”  With this discovery, Dr. Greenawalt revolutionized chiropractic. He stopped the “revolving door” for thousands of patients, and gave their DCs a tool to address the cause of the subluxation and provide positive long‑term results.

The Philosophy of Feet

Some chiropractors see themselves merely as a secondary “complement” to medicine. The message they convey is, “If drugs don’t work for that sore back, come to me and I’ll try to relieve the pain.”

Chiropractors may also restrict themselves to those patients who present a list of symptoms. After the patient is relieved of these symptoms, the chiropractor relieves himself from providing further care.

Many subluxation centered doctors limit themselves to providing adjustments to correct existing subluxations, rather than looking at the big picture and performing what they can to prevent subluxations from occurring.

I read a fascinating article by Will Tickel, DC, whose book “Stirrin’ it Up! A baby boomer’s look at Life, Liberty, and the Pursuit of Imperfect Bliss,” is as insightful as it is funny. Dr. Tickel’s article reminded me of one of Dr. James Parker’s sayings, “Don’t let the size of your shoes determine the growth of your feet.”

Dr. Tickel applied this same premise to the use of orthotics in his article, “Don’t let the shape of their shoes interfere with the growth of their being.” He persuasively argued that, “philosophically, orthotics support the concept of vitalism.” That’s a lot to ask from insoles, but it’s absolutely true. The concept of vitalism boils down to the simple notion that the body has an inherent self healing mechanism. Chiropractic philosophy states that a DC’s job is to facilitate that mechanism and when possible, remove interference that can hinder it.

When a patient suffers foot deviation such as over pronation or unequal gait, that biomechanical imbalance serves as interference to the innate healing process and can be a direct cause of subluxations.

As Dr. Tickel said, “When the reflex relationship of the feet to the entire organism is considered, foot biomechanics sensory awareness and afferentation – becomes a crucial step in the healing and restorative process, as well as in the maintenance of health and disease prevention. From a healing perspective, custom orthotics greatly aid the body’s adaptive or adjustive capabilities.”

If chiropractors continue limiting themselves, they may not be open to providing orthotics to their patients, or addressing this basic cause of subluxations. Thus, their patients are deprived of an extra level of care.

DCs must cautiously decide which services and products to provide for patients, and should use only what contributes to patient health. For business matters, chiropractors should focus on services and products which do not demand unreasonable amounts of time and effort.

When choosing to help remove the interference caused by improper foot biomechanics, doctors must decide which orthotics to offer. As Will Tickel pointed out, chiropractors should not let the shape of their patients’ shoes interfere with the growth of their being and should not allow their limited ideas of chiropractic interfere with the growth of their practice and profession.

Some points/comments. NeuroInfiniti has:

• “completely changed my practice” …
• … “rekindled my love for chiropractic” …
• … “enabled me to show patients the root cause of their symptoms” … and
• … “increased patient visits.”

Powerful stuff! Well worth watching if you can spare 10 minutes.  Bottom line, we need to remember that every symptom/disease stems from the nervous system. This system is right in line with chiropratic’s ability to put bodies back into healthy balance so they can heal themselves.

But the profound truth is that when people see the benefits of this treatment, they immediately begin to ask: how can my loved ones take advantage of this? That’s a 180-degree shift from practicing without NeuroInfiniti, when we would more commonly have to convince patients that chiropractic could benefit their family, friends and neighbors.

Watch the video for more, it’s just under 10 minutes.