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Posted on 09-08-2014

Continuing Your Education with K. Jeffrey Miller, DC, DABCO

Advice for Young Doctors

When I began practice, I was just shy of my 25th Birthday. I was young and I looked it. I had been told this would be a problem when starting a practice--and it was. Older patients often paused when they entered for care. They knew a brand-new doctor meant an up-to-date education, but little or no experience.

One of the first patients I saw was a 72 year old man with lower back pain. After performing his history and examination, I asked if he had any questions for me. He was quick to respond. Staring at me intently, he asked, "How old are you, son?"

This bothered me, so after he left, I began wondering what to do about it. My first thought was to make a bigger deal out of my state-of-the-art education. I'll put my diplomas in a more prominent place, was my first thought but that didn't last long. It was March 1988 and my diplomas were dated October 1987. They were impressive-looking diplomas, but if anyone looked closely, the dates would counteract the effort and possibly make things worse. 

The oldest thing I had on the wall was a plaque I'd received for completing an X-ray seminar series in 1986. That really wasn't going to help either

I had heard wearing a white lab coat and growing facial hair could help the situation. I tried the white lab coat to look more "doctorish" and "authoritative," but it proved to be a pain. I hated it. It just wasn't me. I thought about growing a mustache or beard to look older, but I knew theses weren't my best looks. That idea died completely when I read an article that reported Americans did not trust men with facial hair. 

One day a patient my age came into the office. There was something about the way he spoke to me that left me with the impression he thought I was older than him. I was the only one who knew both our ages. Maybe there was something that made him think a doctor had to be older than him. I don't know.

He was very worried about his condition. To comfort him, I told him not to worry unless I did. He agreed and then said "You've probably been through this a dozen times, so I trust you.": I thought, if you only knew, and moved on quickly, happy he'd relaxed.

I thought about this interaction for several days. I thought about the assumptions people have about how long it takes to be a doctor. I thought about the fact that most people don't really know how long it takes to be a chiropractor, how our internships work or their length. I also thought about a statistic I'd heard at about the same time this happened regarding back pain. One of every three people who experience back pain experience it repeatedly.

Mulling these facts over made me think there had to be a way to use the information to downplay my youth and inexperience, and assure older patients. Here's what I came up with:

- "One in every three patient with back pain experiences it repeatedly" was a medical statistic. It meant 66% of medical cases would be acute and 33% would be chronic.

- The statistic would likely be reversed for chiropractic; 33% of chiropractic cases would be acute and 66% would be chronic. This would be due to chiropractic being a second choice or a last resort for many patients. 

- I would need a tool to address both the acute and chronic patients, but especially the chronic patients

- It might be an advantage that most people did not know how long it takes to become a chiropractor, how long our internships last or how many patients we see during our internships

This thought process led me to the following scripts for addressing patients' concerns. I used them at the end of each report of findings.

Acute Patients: "Before we proceed, we need to be in agreement on something. This is your first experience with back pain, but I have been through this with dozens of patients. So, I am going to tell you not to worry about how things are progressing unless I am worried. If I become worried, then I'll tell you and we will discuss what we need to do. Otherwise, don't worry. I know you will have questions and concerns, and I want you to bring those to my attention; but don't get upset before we have had a chance to talk. If you worry unnecessarily, you will tense up and you will not respond to care. Can we agree on that?"

Reminding the patients it was their first episode, and following that point by saying I had been in the same situation with dozens of patients, let the patients know in a subtly way that despite my age, I still had more experience than they did. Note that I said "dozens";that was as far as I could stretch it regarding the number of patients I had seen. Again, they really didn't know the true number. Later, this would become "hundreds" and now "thousands."

Keep in mind that there is nothing misleading about this statement. Even the youngest, least experienced chiropractor knows more about back pain (and other musculoskeletal conditions) than the average patient.

Telling the patient I would decided when to worry and would address what to do if we needed to worry also told them I was in charge. Telling them to express their questions and concerns let them know that despite being in control, I was still interested in their concerns. Telling them that tensing up would slow their progress gave them a reason not to worry.

Chronic Patients: "Before we proceed, we need to be in agreement on something. This isn't your first experience with back pain, so I know you know something about it; but I am going to tell you not to worry about how things are progressing unless I am worried. I have been through this with dozens of patients. If I become worried, then I'll tell you and we will discuss what we need to do. Otherwise, don't worry. I know you will have questions and concerns, and I want you to being those to my attention, but don't get upset before we have had a change to talk. Again, I'll tell you if there is a need to worry. If you worry unnecessarily, you will tense up and you will not respond to care. Can we agree on that?"

This script is identical to the acute patient script, with the exception of acknowledging that patient's previous experience with back pain. I had to acknowledge the patient's experience and that they know something about back pain. Note I said, "you know something about it"" I did not say, "you know all about it." I had to acknowledge their experience, but not make them the expert. The rest of the script serves the same purpose as the first version did for acute patients.

Did this work? The majority of the time, it did help. There were still some patients who thought of me as a "young whipper-snapper" and had a hard time trusting me until I proved I could help them feel better.

A few never trusted me. One of these patients was Scott, a gentleman who had a bad sacroiliac joint. He did not trust me in part due to how young I looked and in part because I'd worked in a restaurant with his wife when I was a teenager. He kept thinking of me as that kid he knew back in the day. I worked on him for a couple of weeks with minimal success before he gave up.

One day I was standing outside a Wal-Mart helping our local health department with a survey. Scott saw me and came over to say hello.

"You remember me?" he asked. It had been a long time, but I said, "Yes, Scott I do."

He said, "I still got that bad hip. You couldn't do a thing with it, could ya" "You're right", I said, "You should let me try again.

He seem surprised and asked, "What would be different this time?" To which I replied: "I have 10 years of experience now." He laughed, but I never saw him again. You win some and you lose some. My script gave me a point to work from with more confidence and helped in the majority of cases. Even now, after "thousands" of patients, I still use it. 

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