My Fault?

Had a new patient come in last week.  Super nice guy.

After the consultation and exam, I had him relax for 15 minutes under the heating dome.  After that, I gave him his first adjustment ever.

"Wow!"  he said.  "I feel better."  He went on to say, "I'm going to get my wife to see you.  She'll love this!"

I wrapped things up with my recommendations and then Nicole helped him schedule his next appointments.

But he calls this morning.  Tells Rica, "I don't think I need chiropractic."  Cancels all his future visits.

So that's that.  When Rica reports to me what happened, first thing I ask myself, "What the heck did I do wrong?"

I thought the first visit went as well as any first visit could go.  But obviously something changed.  Something triggered a change of heart for this patient.

My fault?

Maybe.  But I can't dwell on it.  I really can't see any particular failing on my part or my staff.  Nothing that stands out.  So rather than speculate, worry, fret and let discouragement build...

I decide to simply let it go.  Let him go.

And focus instead on what I can do for the next person who walks in. 

PV or $?

To all the chiropractors reading this:

Would you rather, over the course of one working week, adjust 300 patients-- collecting $10 for each adjustment or instead, choose to adjust 50 patients at $60 an adjustment?

And what if you had to live with this choice as the PV standard and set fee for the rest of your career?

What would you choose?  And why?

The Pain-Killing Adjustment

Very often, many times a day, a patient will hop onto the adjustment table with pain.  Doesn't matter if I'm seeing a brand new patient or a "chiropractic family member" on her 400th adjustment.  More times than not the person on the table will inform me of some sort of discomfort, achiness, tightness, distress...

What I immediately try to assess is the following:

1. Location of the pain
2. Specific anatomical source of the pain (muscle, ligament, disc, nerve, joint articulation, etc.)
3. Pain trigger (stress, poor posture, trauma, dehydration, etc.)
4. Severity of pain (V.A.S. 0 - 10)
5. How effective an adjustment would be to help the pain go away
6. What technique would be best to adjust the spine to help the patient feel better

This assessment probably takes about 30 - 90 seconds to do in my head.  Based on what I uncover, I may decide to help my patient get some relief before the adjustment (which may facilitate a better, more effective adjustment) with some adjunct care.  Perhaps we'll do some ice, or infra-red, or put on a TENS unit, or do some traction.

Other times, based on the assessment I'll decide to simply adjust the patient.

Regardless of the technique-- be it Diversified, SOT, CBP, Activator, Gonstead, or a combination of techniques, more times than not, after the adjustment (an adjustment with or without adjunct therapies) most patients will get up off the table, move around a bit and say, "Wow!  Thanks, Doc, that feels a whole lot better!"

Why?

Why does the adjustment kill pain? 

When looking at subluxation as a complex-- subluxation being the condition of the spine that affects proper motion, muscle function, nerve function, disc function and also a factor causing accelerated degeneration in terms of DJD-- chiropractors will be inclined to think that any pain reported by a patient is, in fact, linked to one or more components of the vertebral subluxation complex.  So lets run through some facts:

• Subluxation is a cause of pain in terms of how it affects the scructures of the spine
• The damage to these spinal structures may occur in an instant of trauma or it may take months or even years to develop into a manifestation of pain
• An adjustment's purpose is to restore proper spinal alignment and function
• The adjustment does NOT mend strained muscle fibers, heal sprained ligaments, renew degenerated discs, or even restore a damaged nerve back to perfect healthy function
• Over time, if the adjustment is successful in its purpose, the body may heal areas damaged by the subluxated spine.  Over time.

Therefore, how does the adjustment kill pain "instantly" if the pain is due to damaged structures (even if these structures were damaged due to subluxation) like the sprain, the strain, the inflammed disc, etc?  We know time is required in all processes of healing.  So it would be incorrect and foolish to think that the adjustment, by correcting spinal alignment and thereby correcting nerve function, would in a matter of seconds heal those damaged body parts that were causing pain in our patients.

But here they are, seconds after the adjustment, telling us that their pain is gone.

Why?

The straightest of the straightest chiropractors would tell me that it's all about innate intelligence.  That pain is the body's way of telling us that there exists dangerous nerve interference caused by subluxation and once that interference is removed, that pain signal is no longer needed and so our innate intelligence gets rid of it-- regardless of the specific pathology.

Others may contend a gate-theory approach.  The mechanoreceptors activated by the adjustment block the flow of pain sensations along the same nerve fibers.

Does it matter?

Not to me.

I am here to serve my patient by providing their wants:

Pain relief.

And more importantly, I am here to serve their needs:

Optimal health through an optimal nervous system by way of an optimal spine.

The thing is...

if I ignore there "wants", very few patients will trust me in terms of delivering on their "needs."

There are those patients that have made the "need" their "want."  But for the most part, educating the patient on what they really need from chiropractic is an ongoing process of love, faith and dilligence.

Not the ol' bait and switch.

Bruce Lee Would Have Been a Great Chiropractor

Chiropractic is a lot like martial arts. For one thing, the chiropractor accomplishes his purposes through contact with another person. Granted, the martial artist is trying to hurt the opponent and the adjuster is trying to help the patient heal . . . but you catch my drift.

Also, just as there is a myriad of ways to fight, the techniques available to the chiropractor are also many in number. There is the widespread, most-used Diversified technique, the Gonstead technique, Chiropractic Biophysics. Some doctors use the Activator (the one that utilizes the clicking instrument). Pettibon. Drop Table. SOT. Hole-in-One.

And on and on.

We even have some non-traditional techniques that incorporate more of a light touch to the back instead of the usual thrust to the vertebra. Examples of this include Network and B.E.S.T. techniques.

And just like the traditional martial artists, chiropractors for decades have, for the most part, latched on to one style. A style that seemed to suit them best. Then just like the black belt in karate who always uses karate against his opponents, or the Tae Kwon Do master who always fights with Tae Kwon Do, the Gonstead chiropractor would tend to adjust each and every patient the Gonstead way. The Activator doctor always with the activator. And on and on... you catch my drift.

Then along comes Bruce Lee.

He teaches his students to be like water. Formless. Flowing. Finding shape only in accordance to the environment and opposing forces. Instead of imposing our style on the other, we should adapt form and flow to what the opponent dictates.

Chiropractors must do the same. We should not trap ourselves to rigid technique boundaries that force us to care for our patients with predetermined styles, strict protocols, and inflexible care plans.

We need to approach each patient as an individual and adapt our clinical adjustments according to their specific and unique needs. If Mrs. Sakai, an 80 year old woman, needs the light touch of an activator, go at it that way. If the next patient, Kealii, a FedEx handler needs a strong side posture diversified thrust to L-5, go get 'em, bro!

Flow

The following is pasted from Wikipedia:

http://en.wikipedia.org/wiki/Flow_%28psychology%29

"Flow is the mental state of operation in which the person is fully immersed in what he or she is doing, characterized by a feeling of energized focus, full involvement, and success in the process of the activity. Proposed by psychologist Mihaly Csikszentmihalyi, the concept has been widely referenced across a variety of fields.

Many other terms and idioms exist for this mental state: to be on the ball, in the zone, in the groove.

As Csikszentmihalyi sees it, components of an experience of flow can be specifically enumerated; he presents the following:

1. Clear goals (expectations and rules are discernible and goals are attainable and align appropriately with one's skill set and abilities).
2. Concentrating and focusing, a high degree of concentration on a limited field of attention (a person engaged in the activity will have the opportunity to focus and to delve deeply into it).
3. A loss of the feeling of self-consciousness, the merging of action and awareness.
4. Distorted sense of time - one's subjective experience of time is altered.
5. Direct and immediate feedback (successes and failures in the course of the activity are apparent, so that behavior can be adjusted as needed).
6. Balance between ability level and challenge (the activity is neither too easy nor too difficult).
7. A sense of personal control over the situation or activity.
8. The activity is intrinsically rewarding, so there is an effortlessness of action.
9. When in the flow state, people become absorbed in their activity, and focus of awareness is narrowed down to the activity itself, action awareness merging (Csikszentmihalyi, 1975. p.72).

Not all are needed for flow to be experienced."

Achieving flow in my life is a constant goal.  When I am adjusting patients, on the golf course, communicating with my family, or even playing a good game of chess, flow is what it's all about.

To me, flow equals joy.

And the antithesis of flow is that merging point where lack of a challenge meets poor aptitude.  This, repeated over and over, equates to a life of apathy.

Those that seek out the easy roads in life may come to know fun and pleasure, but they will never know of flow.

Mas El Salvador

More.

Now that I'm home and can reflect back on the whole experience, I will now try to express in words a few of the things that my heart has learned:

1. The chiropractic adjustment is truly powerful.  When a doctor delivers an adjustment with love and confidence and a patient receives it with faith and gratitude, miracles happen.
2. I have been blessed with much in my life, but for the most part, my thankfulness for what I have has not been adequate-- and my lack of appreciation, from a certain perspective, is cause for embarrassment.
3. Convictions are only strengthened through sacrifice.  Without tests of courage and welcomed adversity, whatever beliefs we cherish will eventually wither away.
4. Just as there is sadness among the wealthy, there is also great joy among the poor.
5. We are all brothers and sisters.  Everyone.
6. Chiropractic is truly a science, a philosophy and an art.  As a chiropractor, I must embrace all three aspects so as to think, feel, and act in a manner that may best serve my patients.
7. Without the love and support of family and friends, my potential is limited and my achievements meaningless.

El Salvador

I'm writing this entry in the business center of the Hilton Princess San Salvador.  It is Saturday morning.  The mission completed.

I want to record a few of my thoughts about this experience right now while still fresh in my mind.

What a week it has been!

There was a total of 72 doctors and chiropractic interns who made it out to El Salvador to serve.  There were chiropractors from all over the U.S., including California, New York and, of course Hawaii. (Represent!)

And no, we were not in a nice hotel the whole week.

After landing in El Salvador on Sunday, we travelled down the road about 15 miles south of the airport where we waited at a beach for the whole party to arrive.  Around 4 PM when everyone finally made it, Dr. Guthrie and I loaded our luggage and portable adjusting tables onto a mini-bus and headed to San Salvador, the nation's capital, about a 45 minute drive.

We dormed at a Jesuit retreat high in the mountains overlooking the city.  The rooms were clean and neat, but the beds were a bit old and saggy and there was no hot water for the shower.

We started on Monday.  Each doctor teamed up with a few interns and was assigned to a different location in the city.  I was able to work with three interns from Life West Chiropractic College: Laelle, Tammi, and Doug.  We loaded up our things in a van and travelled to the Central Marketplace of El Salvador.

The Central Marketplace covers about 10 blocks.  It's basically a huge swap meet where the vendors sell everything from fruits, live chickens, homemade wallets, dead fish, rat poison, toilet paper and everything in between.

The conditions are not good.  I may not be the cleanest and neatest person in the world, but the grime, flies, and strong smell throughout the mercado was almost unbearable to me.

The only thing I dared to buy was bottled water.

In the middle of the mercado stands a building that houses a small medical office, preschool and union meeting hall.  It was there that we set up our one week chiropractic clinic.  From the minute we opened, there was a huge patient waiting list.  We adjusted from 8 AM to 4 PM each day breaking only for a short lunch.

The people of El Salvador are a very humble, friendly people.  A lot like the local folks in Hawaii, except for the most part, very poor.  I was told that the average worker in El Salvador makes 2 dollars a day.  Most cannot afford any medical treatment and medical insurance is limited mostly to government workers.

For some people, we were the first doctors of any kind that they have seen their entire lives.

On the first days of the mission, I focused on what I could to alleviate my patients' pains.  They were all hurting so much!  Chronic shoulder injuries, displaced knee caps, muscle spasms throughout the back.  I saw old ladies with fractured ankles that never healed right and young men with necks that wouldn't turn. 

But after a few days, I realized that trying to help them by only trying to take away the pain was not the best course of care I could offer them.

With only one week to make a difference, I asked myself, what could I do beyond getting rid of some of their pain?  What could I do best to serve them?  It was around Wednesday that I realized that my duty was not to chase pain; my mission purpose was to adjust!

I was there to restore power.

As the patients lay on my table, I reminded myself that this may be their one and only chance for them to receive a chiropractic adjustment.  Find the subluxation. Visualize how that vertebral subluxation was impeding nerve flow.  Understand specifically how that blockage of nerve flow was stopping the expression of innate intelligence and how that limited them from experiencing total wellness.

Then use my hands, praying for direction, to correct that subluxation.

With the subluxation corrected, the vertebra restored to proper position, and the innate intelligence within the flow of nerve energy-- my El Salvadorian patient might very well enjoy life at higher level of true health.

What a blessing it has been to be able to enjoy chiropractic at it's simplest, purest form! No insurance documents, no treatment plans, no x-rays, no financial exchanges!

Just a small gift I was able to share with many of my El Salvador brothers and sisters.  A gift of chiropractic.

There is so much more I want to write.  I'll continue when I get home to Hawaii.

"He would have nothing to do with the thorns must never attempt to gather flowers."

^{--Henry David Thoreau}

Not Selling My Time

Every once in a while, a new patient will come up off the adjusting table after I'm done and ask, "Is that it?"  As if they are surprised the treatment was so short.

My adjustments usually last about 3-5 minutes, sometimes a bit shorter, sometimes a bit longer, but in that ball park.  I can see how a patient might be a bit bewildered if he or she was expecting a session similar to that of an hour massage.

There is a tendency in some people to judge the value of a service by the length of time the provider puts into the work.  The shorter the time, the lesser the value of that service.

But my patients do not pay me for my time.

If you are a patient or client that demands "x" amount of time given to you by your service provider-- whatever profession it may be-- in order to justify "x" amount of payment, consider the following by Harry Beckwith found in his book Selling the Invisible:

A man was suffering a persistent problem with his house.  The floor squeaked.  No matter what he tried, nothing worked.  Finally he called a carpenter who friends said was a true craftsman.

The craftsman walked into the room and heard the squeak.  He set down his toolbox, pulled out a hammer and nail, and pounded the nail into the floor with three blows.

The squeak was gone forever.  The carpenter pulled out an invoice slip, on which he wrote the total of $45.  The customer was perplexed!  $45 for less than five minutes of work?

The carpenter took back the invoice and added two line items:

Hammering........$2

Knowing where to hammer........$43

_{(page 138-- slight change by me)}

Chiropractic and the Stock Market

People invest their time in chiropractic care the same way money gets invested into the stock market.

Foolish investors expect huge returns in a short amount of time.  When the rewards do not come fast enough, a lot of blame is passed around.

Like the investor of a good stock, a chiropractic patient will have good days and bad days.  Many experts would call it a mistake to sell shares of a blue chip just because it suddenly dipped in price.  Similarly, I tell patients to expect "dips" in their chiropractic care from time to time.  There will be pain flare ups from time to time in between those days when the body feels great.

Like the DOW or the NASDAQ, if we were to chart a chiropractic patient's progress, the graph line would go up and down and up and down and up and down.

But, the overall trend will show improvement and progress.

A person who cashes out of a good investment too early because he or she is discouraged by a loss or plateau, often regrets it.  Down the road, if only they were patient and held on a little longer, they would have seen enormous profits.

So often it is the case with many chiropractic patients.  After one or two treatments, they are discouraged that they are not yet 100% pain free, so they abandon their care plan and dismiss chiropractic as a "failed investment."

If only the patient could be just a little bit more patient.